Tuesday, August 19, 2008

Call of the Sirens (Part VIII)

Our scene: A darkened patient room in a large urban teaching hospital. Not particularly nice but not grim, either. Think tan vinyl flooring and grey laminate counters, but cleanish. The time? Between 5 and 6 am. There is a human-shaped lump on the bed under the beige hospital bed spread, breathing rhythmically in a narcotic-induced sleep. A lone figure in pea-green scrubs and short medical student white coat, pockets bulging with assorted paraphernalia, stethoscope draped 'round the neck, silently creeps in, making no sound, holding her breath. In one fluid movement, she pops one end of the stethoscope into her ears and snakes the other end under the covers and onto the patient's upper abdomen (the 'epigastrium', for those who enjoy such jargon). Holding it there for a brief 3 seconds, she then withdraws from whence she comes, out the doorway, to join the other identically attired members of her surgical team, 6 in all, 2 with short med student coats, 4 with long housestaff coats (2 interns, 1 junior resident, 1 chief resident). In terse whisper, the interloper imparts the following, "No complaints. Dressing intact. Breath sounds clear. Cardiac--regular rate and rhythm, no murmurs. Bowel sounds present." One of the members of the team quickly scribbles her words into the patient's chart. Another scribbles some orders and puts it with the rest of the team's charts on the rolling chart rack. On to the next room, where the performance is repeated with little-to-no variation.

Thus are pre-rounds on the surgical team.

Heaven on a scalpel.

  • Always round before the patient is awake and family members are present. Talking to patients and especially family, wastes time. The nurses can read your note and take care of all that touchy-feely bullshit.
  • Always have the lightest team member examine the patient, the better to creep in and out without waking anyone. (See above)
  • Placing the stethoscope in one place allows you to (theoretically) examine all 3 organ systems (lungs, heart, gut) without all that needless mucking about that internists are so fond of, placing their stethoscopes here and there around the torso.
  • All this stealth is vital for the team to have rounded on all the inpatients ahead of time in order to be in the operating room by 7 am sharp: gloved, gowned, scrubbed, surgical instruments in hand, attending pimping away. ("So. Dr Piffle. What is the order in which one encounters the vessels that supply the GI tract coming off the aorta, in descending order and is each anterior or posterior to their corresponding venous counterparts?" "Errrrrrrrrrrrrrr....")

Ah. The surgical rotation, where one learns the 4 cardinal universal rules of surgery:

  1. Trust no one.
  2. Eat when you can, sleep when you can, pee when you can.
  3. The esophagus is not your friend.
  4. Don't fuck with the pancreas.

Contrast these with the 4 rules of internal medicine, as told to me by a rather cool attending:

  1. Medicine is not a science, it is an art based on science.
  2. There are at least 2 ways to do everything.
  3. Every patient is an n=1.
  4. If you're not having fun, something's wrong.

Taking #4 up there: see, the thing about surgery, is that it is fucking fun and really simple. Not the surgeries themselves, but the approach to medicine. You are congratulated for the shortness of your notes and your ability to turf (transfer the care of) any patient who is not in need of surgery right now, to a non-surgical service. You don't have to waste time on all this differential diagnosis stuff. Who the hell cares why Mrs Jones is demented, all you care about is if Mrs Jones is a surgical candidate. If not, turf her.

Turf her good.

(An aside-- that's one thing that reallyreally bugs me about all these medical shows. See, there are strongly delineated lines between medicine and surgery, especially in a teaching hospital. Surgeons operate and do the post-operative (including the surgical intensive care unit) care. They do not have anything to do with medical issues. They don't manage the insulin. They do manage the pain meds. The patient with some sort of unknown fever, unless there's an obvious surgical source, would never be admitted to a surgical service. The patient would be admitted to medicine, perhaps with a surgical consult as to whether or not surgery might be indicated, but NEVER to a surgical team. Also? There are distinct surgical sub-specialities. Don't mix general surgery with orthopedics, ob/gyn, ENT, urology. They do not generally cross specialities. A general surgeon won't be operating on a deviated nasal septum. Nor will that surgeon be fixing a heart or doing neurosurgery. And vice versa. Pediatric surgeons generally don't operate on adults and vice versa. Got it? Rigidly defined roles. There are exceptions but they don't practice in large teaching hospitals.)

I also adored the surgeries, themselves. All that glamorous, sterile attire. The appropriate etiquette. How to scrub--start by cleaning under the fingernails with the enclosed nail pick, then lather up with the sponge side, then scrub 10 times each part of each finger, then the backs of the hands then the palms, rinse with the hands up, letting the water drip down the arms and not off the fingers. How to move through a sterile field. How to change positions with a colleague at the table-- the one closest to the head turns out of place, rotating back-to-back, and turning around again to face the table. How to stand--arms crossed, hands under armpits or hands held in front of the chest. Never below the waist. Below the waist is not part of the sterile field. Neither is the back nor above the shoulders. How to gown and glove oneself (although the surgical circulating nurses will often do the honors of assisting with the donning of gown and gloves) while maintaining sterility. One does NOT break the sterile field or one will find oneself in small pieces in several parking lot dumpsters.

How not to pee for hours and hours on end. Drinking fluids is to be carefully timed. It's OK to have some coffee up until, say 6 am, but not later, unless it's a short case. Some cases go 12-14 hours.

How to stand so as to try to diminish the pain in your legs, your back, your arms. How to ignore the hunger. The fatigue. How not to look weak. How to bond with your team.

That last one was key, I've no illusions. I adored surgery because of my team. The Chief Resident was an amazing woman who actually enjoyed teaching and let her students do lots. The Jr resident was a middle aged guy who had been a cardiothoracic surgeon in his Eastern European country before he immigrated and had to do all his training all over, again. So he was very happy to have the students do procedures. As he was so qualified, our team would sometimes have 2 suites going at once, with the Chief, an intern and a student in one room and the Jr resident with the other intern and student in the second room, the attending wandering about between the two and the lounge. What's not to love?

And so, why the hell didn't you become a surgeon, m'dear?

Ah. First, because I knew my personality, and while I loved it, I knew I didn't have the soul of a surgeon. I don't like crises. You can't get away from the crashing, life-and-death, what-the-hell-are-you-going-to-do-right-this-minute-Doctor-this-person-is-dying stuff, but it's so much more common in surgery. The tools I have as an internist are the drugs, the endotracheal tube and ventilator, the cardioversion paddles, the labs and scans and the consultants. Not quite in the same league as what the surgeon faces with someone who's bleeding out.

Also, most surgeons are assholes. It's true. I've known lots of wonderful surgeons, but most are not. I'm not fond of assholes.

And finally, Charles would have divorced me, I'm sure. The residency is brutal, lasting 7-10 years for general surgery, depending on the program. Call is usually every other night. The off call days run 14-16 hours. It's the speciality that brought us the phrase "The problem with only being on call every other night is that you miss 1/2 the good cases." That in itself was enough to bring me to my senses and to make me an internist, with my drugs and scans and long, involved differential diagnoses. And to care why the hell Mrs. Jones was demented, because there are a few rare things that can cause reversible dementia and the surgeons sure as hell weren't going to look for them.

After my glorious weeks as part of the general surgical team, I headed off to my surgical elective, anesthesiology. Good god, what a shitty speciality. All fiddly deadly drugs and monitoring. The gas passers live a life, as the saying goes, of endless boredom punctuated by bits of sheer terror. As students, we were paired up with an anesthesia resident (no interns; anesthesia residents generally do a medical internship) with an attending overseeing. One attending in particular, the Chief of Anesthesia, enjoyed the reputation of being a remarkable jerk and was, for some inexplicable reason, heavily into professional wrestling. As students, we had to call the surgical patients we were to anesthetize the next day, the evening before, and go through all the questions they'd already been asked by the residents. The same EXACT questions. Which I thought was beyond bogus, especially, as we all know, I really don't like talking on the phone, especially cold calling strangers for no reason but to bother them on the night before their surgeries.

So I made it a rule not to call them.

Which, as luck would have it, came back to bite me in the ass the last day of the rotation, the biter being the dreaded professional-wrestling-besotted jerk attending. He asked me something that I would have known, had I called the patient (nothing vital to their care, don't worry, just something beside the issue). I said that I didn't know. He asked "Why not", bushy eyebrows descended to an alarming level. I said, "Because I didn't call." Seeming to swell to the size of a large grizzly bear, he thundered, "Why the hell not?" "Because I'm worthless and weak," I said matter-of-factly, looking him in the eye. I was exhausted and, I suspect, not averse to goading him into killing me and relieving me of my misery.

And then he laughed. And laughed and laughed and left for his standing date to watch Portland Wrestling. And he passed me with an acceptable grade.

Always tell the truth, dearest darlings, no matter what. You're likely to be caught in a lie at some point, and who knows, you might provide comic relief to someone. Plus, the truth is always simpler. Like surgery.

So that's how things ended with Diana and surgery, except I still get to wield the scalpel and suture from time to time in the office, with small things. And I still feel a bit whistful as I don the sterile gloves and ask my nurse to pass me the #11 blade.

But I make it a point to always say "please" and "thank you", just so no one thinks I'm a jerk.

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Thursday, August 07, 2008

What I've Learned On My Summer Vacation

I really don't know what I was thinking.

See, a few months ago, when there were still the remnants of all that winter snow in the mall parking lot, the kids were in raptures over one of those crappy little 'fairs' that were set up by the chain toy store. You know the sort: a small Ferris wheel, some sort of half-assed mini roller coaster, probably a tilt-a-whirl, a few win-a-.99-cent-prize by spending $5 and seeing if you can toss a ring around a bottle and some cotton candy and popcorn concessions.

Their pleas of "pleasepleaseplease" were answered with a 1-2 punch of "No!" and "We'll see about going to the big State Fair in the summer."

A trip to the fair in summer, being months away and warm and bright, seemed like just the ticket. Visions of tents pitched on the grass, breezes amidst the trees, parades of well-groomed cows and the like, accompanied by all sorts of fair food. What's not to like? Sort of a grown-up version of our small county fair that we went to a few years ago.

Oh, Stupid-o mio.

Concrete. Miles and miles of concrete overlayed with a cacophony of screaming. Unbelievably overpriced, with tens of thousands (hundreds of thousands?) of people scuffing along in the opposite direction of where ever it was we were trying to get to.

And to top it all off, I inflicted the whole thing on poor pal, Teri, who I've not seen in 2 years. "We're going to the fair! We'll be near you! Do you want to meet up with us and do the fair? We can get to spend some time together while the kids enjoy themselves."

Alas for her and her girls, meet us they did. The cranky, over-heated family who didn't bring enough cash for both riding and eating, or really even just riding. (Who the hell doesn't take credit cards these days, I ask you? That's not just unamerican, it's anti-commercial. Don't they watch TV? Life stops for those who taketh not the bits of plastic.) After a few hours of dragging around, we called it a day and packed it in, leaving poor Teri a little cotton candy colored puddle in front of the cursed Ferris wheel. (We'd gone back on purpose, right before leaving, so Colin could ride it, as promised, but he decided that he'd really rather not ride it after all and just.wanted.to.go.home.) As a topper, Sara succumbed about 1/10th of the way back to the car (conservatively a generous 1/2 mile (1 km) away, swimming like salmon up a stream of lemmings) and so Charles and I lugged her back, between us, Colin dragging behind.

Had we only stopped and indulged the lil' darlings all those months ago with the crappy parking lot fairlet, we'd have saved us all a bunch of woe, not to mention a chunk of change. Live and learn, cupcakes. Live and learn. Trade not the small pain of today for the large woe of tomorrow.


A couple of weeks ago, though, I got to meet another of us, Teresa, out from Seattle to visit the relatives. We met up at the very large farmer's market around the Madison capital square and I got to sit and laugh with Teresa and her sister and daughter while her brother-in-law entertained her niece and nephew. It was, as it invariably is, an all-out gab fest as two people who've never met in person and yet know scads about each other's lives finally get to sit down and sip coffee and nibble baked goods. It's never long enough, is it? And what is Teresa like? Just like she looks: You have to hug her as soon as you see her. She absolutely sparkles. It should come as no surprise to know she teaches kindergarten. I don't know if only lovely people teach kindergarten or if teaching kindergarten makes people lovely. (I strongly suspect the former. 5-year-olds are sweet but I think were it me in a classroom of them I'd be heavily medicated or lobotomized and Teresa is neither.) I forgot my camera but she brought hers and posted one of us if you care to scoot over and wave "Hi" to her.

And while we're on the topic of catching up over the past few weeks, what happened to The Pool? Well, it was replaced with a more modest and demure inflatable one that was used with reckless abandon by kids and dog, alike. When it was about to qualify for protected status under the umbrella of the endangered species act as a habitat for several newly emerging life forms, I emptied it, scrubbed it out and left it to desiccate a bit in the sun before filling it anew. Then one of those freak violent summer storms blew up out of nowhere. It ended up down at the bottom of the pasture impaled on something large and sharp, leaving it with a ragged rent in the side, rendering it no longer either "inflatable" or a "pool". Luckily, the pools are still on sale at an even more reduced price. I did toy with putting 5-6 of them in the cart. I think I will live to rue the day that I did not. I was wondering why Jocelyn was disparaging inflat-a-pools in her comment. Now I know.

Pictures for you

I'm just a-learning lessons left and right, aren't I?


Speaking of learning, I did finally take that agricultural medicine test last week. Not that anyone was really wondering, but take it I did. It was well and truly taken. Now I just need to wait for the results and then figure what the hell I'm going to do with all that newly gotten knowledge about tractor safety and the lot. Assuming I pass, of course. If not, then I guess I'll not need to decide. Win-win.



Here's the two fawns who seem to be growing and learning without their mum. They keep eyeing my vegetable garden but have decided that the tomatoes that have taken over most of the space aren't what they'd really rather eat. Aren't they pretty? I tried to post a larger, cropped picture but flickr wouldn't have any of it for some reason. Trust me. They're adorable and still have their spots.

Pictures for you


Firmly entrenched in the heading of "When Will I Ever Learn" is finding that I have somehow agreed to serve my Network and can be found on the roster of the Physician Practice Committee. Gads. For almost 8 years I had successfully avoided such things but found myself thinking, "Hmm. This could be interesting and a way to make some positive changes in the good ol' firm. And breakfast will be served."

All this must have taken place right before lunch when my defenses and blood sugar were at a double ebb for I found myself responding that I'd be delighted to take a seat at that table. I now find that I've somehow become one of 2 physician leaders of the Patient Access sub-committee of the original committee. That's 2 committees. What were they thinking? What was I thinking? I'm the one who sits in the back and nods in agreement from time to time while eyeing the danishes and wondering if I can somehow snag another one while looking like I'm just stretching, sort of a variation on that old first-date-in-the-movie-theater move where his yawn ends with an arm around your shoulders. Now I'm to be at the head of the table at the horrible hour of 7 am, expected to contribute many things of worth AND I've not heard a word about food at these sub-committee meetings. I fear a large tumor has taken over the logic and reasoning bits of my frontal lobe. Here's hoping it rapidly eats away the rest of my higher functions and personality so I won't suffer too long. As an added bonus, we're to round up several other physicians to serve along with us. Ever try lining up docs to do such things? Forget herding cats. It's like herding birds. Birds who never return your calls. Can't say I blame them.


And while we're on the subject, is there anyone else who would be horrified to find that the gown you were handed by the nurse for your daughter to change into at her kindergarten check-up/meet-her-new-doctor-now-that-your-insurance-has-changed appointment had 8 McDonald's characters spread across the front in various medical garb, all grinning horrifically?

I felt like putting posters of "Supersize Me" up all over the exam room. Good grief.


So, that's my hiatus in brief. Well, not really brief, actually.

I'll leave you (and you, Teresa as I promised you one, and you, Jocelyn, as you appreciate the inappropriate conversationalist that is the manic gardener, and you, Teri, as you are a true friend as you're still speaking to me despite the horror that was the state fair) with the following of my lovely tree lily. It topped out at over 6 ft (2 m) high and smelled of sweet, sweet summer. Don't look too closely as each cup was full of gorged and stupefied earwigs. The good with the bad, as is life.

Pictures for you

Hope the rest of you are well and you avoid state fairs and committee meetings.

(Oh, and if you happen to not look where you are vigorously weeding along your raised garden bed, and put your hand --gloved, thank god, but inadequately so-- in a hornet's nest, this will lead to a most painful stinging, causing a stream of fuckingshitfuckingshitsonofabitchFUC!KING!SHIT! to issue from your mouth as a reflex, and your small children will learn how to correctly pronounce, enunciate and vocally inflect those most taboo of words. They'll be the pride of the school playground in a few weeks.)

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