Call Conundrums

This weekend is a call weekend. And tomorrow I am off (after 8 and once I give appropriate handover), followed by a trip half way across the country to present my research. I am excited.

My calls lately have had some odd streaks to them.

For instance, I had one that was, well, a complete surprise.

The program administrator sent me my schedule for the next block including my 5 dates for call in the next four weeks. I didn’t get a copy of the master call schedule, but so long as I knew when I was on call, that is all that really mattered. I could call locating to find out who the staff was.

But, then, I was in teaching one day when one of the staff docs came in and gave me a post-it note, said we were on call together and all his info was there and left. I though it was for when I was on with him that coming holiday Monday.

Then I read the post-it. It informed me that we had 2 beds available, the floor was quiet and that we were on together tonight.

But I wasn’t scheduled for call. So I thought.

Turns out I was according to the board in the nursing unit. And Locating. Apparently, they forgot to list one of my dates when they sent out my schedule. Fail.

So much for a date night out with Patrick.

Call is the worst when you aren’t mentally prepared for it. Even if it is home call. I was rotted.

This weekend, I was super tired Friday night and decided to go to bed early after a very quiet night. I went to bed just before 10 and fell asleep. I woke up to my pager just after 11 with a “I wanted to call before you went to bed” call. Little do they know I am like an old person and was already asleep for an hour.

Yesterday, I was in and out of the hospital much of the day. So much so, the security staff (two of them) got to know me by name.

Also yesterday, I had to go to the university library to use their computers to get access to SPSS, the statistics program I did the stats for my research on. This because I discovered the university only licenses the downloads for one year for staff. And both of my supervisors aren’t around to take the time to email computing services and get a new code for me this week.

I get in to the library, which is strangely quiet and am working away when a random guy comes in and sits at the next set of computers away and starts watching something that was making horrifying screaming-like-someone-was-being-murdered noises and other bizarre sounds. I looked around and nobody else seemed to notice. I questioned whether I was part of a weird social experiment for a bit because it kept happening and he was making no effort to turn down his sound or plug in headphones. The sounds of murder had just stopped when my pager decides to go off. And I get a dirty look from some people.

Seriously? We just heard screams of death and other weirdness for the last 10 minutes and the 2 beeps of my pager it took to turn it off is what earns a look of death.

The cat picked up my pager by its “bungee cord” and dropped it in his litter box this morning while I was getting out of the shower. It was in a clean patch, thankfully. I think he hates it as much as I do.

Excuses, excuses…

It was pointed out to me by several people (which blows my mind a little) that I am behind on posting.  By a whole two days.

I know… Mind blowing.

I do skip posts sometimes.  But this week was particularly crazy…

It was just me an a new senior resident this week.  That meant that we were busier overall.  I got to scrub in to a ton of surgeries, which has its pros and its cons.  I must admit, I am feeling much more comfortable with the whole thing (I have mastered the art of cutting and stapling… Kind of like kindergarten), although by Wednesday evening, I thought I might need a foot transplant (I refuse to buy proper OR shoes because I will RARELY use them in real life).

Tuesday night, chemo was running late, so I had to stay until that was over.  It was 7 by the time things wrapped up.  I had been there since before 7 that morning.  I still posted, but I was pretty pooped that night because we were out the night before too.

We had our D-group… aka small group on Wednesday night.  We ate pizza, talked about the resurrection and had a worship session complete with tambourines and other noise makers.  It ran late.  We got in at 9 and I still had to skim my research presentation for the next day and do reading for the ORs the next morning.  So, no post.

Yesterday was my department’s resident research day.  I was convinced to present by the lovely Dr. Bond.  I was terrified of looking like an idiot in front of people.  Somehow the coolness of my research combined with my love for public speaking managed to score me the award for the best rad onc resident presentation and the best overall resident presentation… It included a cash reward that will now enable Patrick and I to do something like go away on a romantic evening or something wild like that… Whoo.  After all of the research festivities, we went out for a drug company sponsored fancy supper.  They lit my desert on fire.  ON FIRE!  I got home at 9 and still had to inform my husband and parents of my exciting news. By the time that stuff was done it was past my bed time.

That leads me to tonight.  I am on call… Yet again.  It seems that happens a lot.  But, at least I have the time to post.  And catch up on some TV (possibly).  There were new shows of almost everything I watch this week… And I am weeks behind on some of them.  We are making butter chicken lasagna (I know… So weird, but it was on sale at Superstore) and chilling out for the evening (unless I get called in, which is likely given my present track record).

Instead of writing a post about something interesting, I decided to do the stereotypical make excuses about why I did not post thing.  I know, it is cliché.  But, I thought it actually does sum up the interesting stuff in my week.  Plus sometimes you need a self-satisfying “wah wah, this is how big my week was.”

I can’t make any guarantees, but things will hopefully be more interesting tomorrow.

How was your week?

Ducking, weaving, shivering and not looking like an idiot… The OR.

I spent the entire day in the OR today.

This makes two days this week.  And tomorrow is an OR day too.

Often, as a junior off-service resident, OR days equal me running around and taking care of patients on the floors.  When the running around is slowed down, you peer at stuff from the back of the room.

However, on this service, the floor work is much less, so I actually get to go and peer at a lot of surgeries.  This can be a good thing.  But, it can get a bit dull.

What?  Dull?  How can surgery be dull, might you ask.

Take these people, and then try to hover around to see what is happening without touching most of anything. Challenge accepted! Image via mediawiki.com.

Well, the thing is, you help get the patient positioned and then while you wait for the team to scrub, drape and start cutting into the patient, you write the orders and some of the operative note.  Then, you wander around the room hovering, standing on your toes, dodging heads and shoulders to try to get a good look at the action.  While the stretch your body into a way that enables you to see stuff is happening, you are being reminded repeatedly by the scrub nurse and the circulating nurse to not touch a million things and be careful of thing blank (these are very important warnings because contaminating a field is a very bad thing).  If you are lucky, it is a laprascopic procedure  for which you can see one of the tv screens.  Then, it is kind of like watching TV or a video game.  If you are unlucky, it is a procedure in a deep hole with a ton of arms and bodies in the way of any hope you had of seeing very much.

Eventually, the ducking, weaving and straining gets tiring.  By that time, they are finally doing something kind of interesting.  You start to space out, daydream.  That is always when the staff asks a question that you are supposed to answer.  You fumble through it.  You stare  at what is happening.  You try to not concentrate on the fact you are freezing and can no longer feel your toes.  You fidget a little.  You try to pay attention.  You try not to fall asleep standing up.

After what will feel like hours (and it often is), you realize that you enjoyed about 20 minutes of unobstructed viewing (most of which was the more senior residents closing) and maybe an hour or less of something that was cool to see… At least from that far away.  The rest consisted of chunks of view, watching people curse, watching people dig around at something you can’t see and some pimping.

You finish writing the notes.  You help move the patient to the bed and take them down to recovery.  You just start to think you might warm up and then you repeat the cycle.

Sometimes, you do get to see more.  And don’t get me wrong, the OR offers some wonderful learning experiences, even if you aren’t right in there in the action.  I have seen some really cool stuff (smelly liver abscesses, giant tumors) from the side of the room.  But, watching people do stuff you don’t fully understand for hours in dreadful. Especially when you are cold and afraid to break something.

We don’t have comfy looking viewing theatres like on Grey’s Anatomy.  I wish we did.  Maybe I could sit there instead.  And see more.  And keep warm.

It looks like much better and warmer viewing up there. Image via greysanatomy.wikia.com.

But, today, I got to mix it up.  Thanks to teaching for the other program, I got to assist in a few surgeries.  Assisting at my level is similar to assisting as a med student.  I retract.  I move the uterus around on a stick.  I suction a bit.  I cut sutures.  I clean up the patient when we are done.

Scrubbing in frightens me.  I lack hand eye coordination that is required to avoid contaminating myself or something else, so although I am fine now, I have been known to walk into undraped limbs or touch things I shouldn’t.  When I scrub, I remember those times.  Also, I am slow at suturing and such, so I am always nervous about looking stunned (even though some might argue I am supposed to be stunned because I am a first year resident).

I swear this has pretty much happened to me. Image via ddxcomics.com.

The awesome part is that you actually get to see stuff and feel stuff and although you get grilled more because you can see and feel (and they remember you are there), you also get to do something and keep a bit warmer.  It is a fabulous place to learn anatomy and about how diseases work.  A tiny piece of me likes it.

I nearly stroked out today though when I was told to assist kind of first assist style with opening the patient today.  Really, the staff was two feet away and helped me, but I did actually use the cautery (first time ever) and cut through the abdominal wall.  And helped with the procedure more than I normally would when I scrub in with an attending and a senior resident.  I was relieved when someone better at that stuff took over, but for a bit, I was kind of being surgical.  Kind of.

Being able to do that stuff is cool.  I can see the appeal.  I still don’t want to do that for the rest of my life.  Or do it very often.  But, it was cool.

Tomorrow, I am back to the freezing and hovering.  But, the first case will at least be on the screens again.  Thank goodness.  Apparently, I will be assisting more next week.  I have mixed feelings about that.  But, I am glad to be learning.  And while I am scrubbed in, I am glad we don’t have viewing theatres like on Grey’s Anatomy to see me look “special.”

Procedure

Image from hoMed.

“Hello, my name is Trisha.  I am the junior resident.  No, this is not my home service.  Please, let me now stick a needle in your abdomen.  Of course I know what I’m doing.”

Such is life off-service.

I am now back in the world of livers again, which means I am back to doing paracentesis (aka draining extra fluid off of people’s bellies).  It is an immediately satisfying procedure in that you see instant results.  It is dismaying because people often reaccumulate the fluid quickly and you have to do it again in a few days to months.

I am not a procedure person.  I never have been.

Don’t get me wrong, I do them.  And I am decent at them (although also a bit slow and shaky).  But, I don’t derive the same sort of joy other people do in performing procedures.

Most of the people I went to med school with liked their given field for the procedures.  You get to do blah to people.  And they get a big kick out of that.

This is what happened to us on procedure day… Casts, IVs and blood draws all around. Plus some pig guts and dummies to boot. Image from medschool.lsuhsc.edu.

I remember med school procedure days.  I thought they were neat.  I love the feeling of fresh casting material and it was fun to be better at taking blood and doing IVs than average (thank you undergrad), but I was never as pumped as some of my peers.  They could practice hand ties and sew pig guts until the cows came home.

Maybe part of it was that I have always struggled with fine motor skills.  And I hate not being the best at something (and I will never be the best at most surgical-type interventions).

Another part of my procedure issue is that I just plain find it bizarre how we learn in medicine by practicing on real people.  Its not like we can learn on fake people.  And we do sometimes get to do stuff with dummies or each other first.  Some things just need to be done on real sick people.  But, nothing is more awkward than telling someone, “yes, you are indeed the first person I have done this to.”  I don’t know many other professions where you actually torment live people (under adequate supervision) for the sake of both learning and their theoretical betterment.

I am a person who learns by reading and understanding, so the whole “see one, do one, teach one,” thing is irritating when I have yet to read about one.    I generally like all procedures better once I have a few under my belt.  Because then I don’t feel like a bumbling fool (or at least less of one).  Competence is a requirement for me to like something, me thinks.

When I was in Nuc Med, I loved injecting radionuclides.  I loved taking blood.  But, it was that along with the other stuff.  The other stuff made the bits of hand-eye coordination cool.  I worked in Specimen Collection for a summer and it was quite possibly the worst job ever.  In fact, I use it to this day as a standard to compare all other terrible jobs… Gen surg is the only thing that came close.  I liked taking blood.  I did not like doing it 8 hours a day, 5 days a week.

My Nuc Med buddies teased me because I have a ridiculous tremor when I do take blood and such.  It scares people at first, but I really am quite competent (and the tremor diminished with increased practice and caffeine tolerance).  They made me promise when I got into med school to not do surgery ever.  Because my tremor would terrorize everyone.  Have no fear folks, that isn’t the only reason I won’t do surgery.

I picked my field for the variety.  And because once I am out, I have the option to not do a whole heaping lot of time-intensive technical procedures.

I like giving immunizations.  I am cool with the odd blood draw (just not an 8 hour day consisting of 100+ draws).  I will do your pap or use a scope to peer at your larynx or sew something up once in a blue moon.

I, however, can’t do that all day.  Or every day.  I love my sit-down chats with people.  I love clinical medicine and tolerate procedural medicine.  I enjoy paperwork and computer work, but most of all people work.

As cool as it is to impale people with large needles and suck fluid out to make them feel better, I like making differences in other ways (like prescribing drugs or radiation or talking).

My kind of instruments! Image from benitaepstein.com.

It is a personal preference.  I know it is an important part of medicine.  And some aspects of Rad Onc are super procedural as well.  It is all about what you make of your practice (and what sites you focus on and how much time you spend on certain sites).

Will I do procedural stuff?

Heck yes.  Everyone does.  And some of the sites I think are cool may require me to do procedures.  And I am fine with that, if I like the procedures and I get the variety that comes with the career I chose.

I will also enjoy the procedural stuff more when it is better within my comfort zone and training niche. Knowing what one is doing and its relevance to the care of your own patients is huge in enjoying it.  At least it is for me.

It is good to know what you like or not like.  But, sometimes I wish I could get the same kicks out of sewing or impailing that other do.  Instead, I grin and bear it and take joy in the fact that it helps that person and that once I grow up, I will be able to somewhat tailor my practice (or defer to the off-service junior resident… Muahahahaha…. Okay, not so much).

Sinking in Sarcoma

Much of my life of late has been consumed by sarcoma.

Thankfully, not because I have one, but because I am doing a presentation at my home program’s resident rounds about them.  And I did one on my last surgery rotation about them.

In fact, it seems sarcoma predominates my current status.  I even saw a kid in emerg last week with a giant belly mass for which sarcoma was on the differential (I assumed more because all I have been doing is reading about sarcoma).  But, I was following up on the case and it turns out I was right… Sadly.  Although there are other things that could have been worse.

Last night, Patrick started decorating for Christmas.

I worked on my sarcoma presentation.

This was the view from my corner of the dining room table (and you know I must be serious when I am actually sitting at a table to do work).

Our blended winter family was spying on me as I worked.  The littlest one was hiding behind my laptop screen.

Our blended winter family was spying on me as I worked. The littlest one was hiding behind my laptop screen.

Tomorrow, the presentation will be over and I can finally use some of my extra time to do something not sarcoma (like catch up on the peds reading I am getting behind on… Or, Christmas shop).  I love presentations though.  And the nerd in me loves preparing them too.  I am clearly not right in the head.

Sarcomas are interesting.  I am focusing on extremity soft tissue sarcomas, so tumors made up of cells that were once muscles, fat, the lining of our joints and such.  There are over 50 subtypes, yet, they are only 1% of adult cancers.

The main treatment of a sarcoma is surgery.  But, good quality surgery specifically.  A good resection can be the difference between life or, well, a short life.

The other big sarcoma treatment is radiation.  Because there are so few sarcomas, there are limited really good quality trials on it and because there are few trials, the treatment, although signs point to it changing, has been fairly consistently surgery followed by radiation.  More and more evidence and practice based observations suggest it might be better to irradiate up front, possibly with chemo.  But, there is little to actually scientifically test it on.  So, it is a debate.  A big one in the field.

This debate came up during my surgical rotation when I presented on the debate itself.  Despite all kinds of retrospective studies suggesting radiation up front could be better, there is only one trial that looked at it and it ended early.   Surgeons are hesitant to send patients for radiation first.  Radiation oncologists would love to radiate first.

But, if patients don’t come until the chunk is out, there is really nothing you can do.  Well, except educate.

That is where good interdisciplinary teams come in.

In fact, I read a study about how the whole decision thing is very profession dependent, despite all of the people being aware of the same literature and guidelines.  Because there is so much ambiguity in guidelines.

Things are changing.  We don’t work as much in isolation.  But, we are still set in our ways.  And we love evidence.  Which is tough when evidence is forever limited by rarity.

I think that is why I like sarcoma.

It is different.  It is a bit controversial.  And it is diverse.

Kind of like people.

It taught me a good lesson in variability in practice, the need for good research and also the importance of the patient (until the last 20-30 years, amputation was the way to go with these… Thank goodness someone had the bright idea to try to improve things).

The whole presentation thing also reminded me that as much as I love this stuff, I still want to do the whole festive thing and pretend to be normal once in a while (aka not secretly fascinated by sarcomas).  And that eventually many things look more fun after hours of work, including the heap of dishes in the sink.

General Surgery is NOT Grey’s Anatomy

Today is an epic milestone for me!  I survived my general surgery rotations… Both of them!  And I liked them.  And did well on them.  What a shock to the system!

Often when I have tried to explain to people that I am on general surgery and have little spare time or sleep and such they ask if it is like Grey’s Anatomy.

No surgery team looks like this. Image from tvlinks.eu.

And thus, I present to you my list of how life on general surgery although with some very superficial similarities, is not like Grey’s Anatomy.

Slightly more realistic surgery team… Slightly. Image from timesunion.com.

To start, the similarities:

  • There really is a chain of command.  Interns answer to senior residents who answer to fellows who answer to attendings.  And sometimes people try to breach that and it can get you into trouble.  And some of the people at the top are nasty or manipulative, but most of them are just doing their job the best way they know how.
  • We really do use pigs and dummies to learn to operate and do procedures.
  • Interns do not see the inside of the OR very often.  And often when they do, it is an emergency, a boring case or something people need a hand on.
  • People do indeed come to hospital with ridiculous problems all the time.
  • Surgery is a tiring and emotionally straining field.  The hours are as crazy as they make them appear.
  • 24 hour call is a real thing.
  • People’s personal lives outside of the hospital keep happening despite all of the work and sometimes get pretty messed up as a result of all of the work.
  • Failing an exam does indeed mean you can be held back a year.

And now, the differences:

  • Nobody looks that good after working 24 hours.  Nobody.
  • Scrubs in real life don’t fit that well.  They are gender neutral and height neutral.   Tall people look like they are braving a flood.  Short people slip on their pants all day.  They aren’t flattering… Ever.

    What Izzy looks like in scrubs. Image from buddytv.com.

    What I kind of look like in scrubs. Image from the craftartykid.blogspot.com.

  • Although some people wear long sleeved shirts under their scrub tops, they are not conducive to going to the OR.  Your face would get eaten for sure.
  • For more face eating… The people on Grey’s often scrub incorrectly.  You can’t touch anything after scrubbing.  One should have their cap and mask on prior to scrubbing.  They fail at this regularly.
  • And face eating again… One wears a mask when entering an operating room in progress.  Always.
  • You can loose your medical license for dating patients.  It is actually unethical.
  • You will get fired for sure if you kill someone intentionally, blow a clinical trial intentionally or repeatedly cause all sorts of trouble by undermining staff, endangering patients and having inappropriate relationships.
  • Jobs do not just materialize from thin air.  Nor do fellowships.
  • You can’t just spend your entire residency doing one type of surgery if you are in general surgery.  Also, ortho is another specialty altogether.  And you can’t just hop from surgeon to surgeon at your own whim.  There are set rotations.
  • I will admit that people have been known, from time to time, to do it in the call rooms.  But, not at the frequency, rate or sheer volume as portrayed on Grey’s.  In fact, it is a rare rebel sort of exception as opposed to the rule.
  • Call rooms are not that nice.  Often they resemble patient rooms or ratty college dorm.
  • First year residents don’t get sent to operate all willy nilly ever!
  • Interns do not only do surgery.  They rotate through other stuff.  You can’t just wander off and do something else at random because you get tired of surgery.
  • Residents in generally do much of the work, but they can’t just  go do surgeries or make all the decisions.  Attendings are still in charge overall.  They can’t go all Christina Yang and mysteriously do a ton of procedures.

    What would happen if interns could operate all willy nilly. Image from medicinepgywhat.blogspot.com.

  • Although I have seen people bring their small children to work, it is usually a very temporary and desperate measure.  They don’t just get passed from nurse to resident to staff member at random.
  • If you call residents by numbers or “dwarf names” you can get charged with harassment.
  • You just don’t air that much of your dirty laundry at work.  Your personal life is your personal life.  You can be friends, but full on arguments about who slept with who at the nurse’s station will get you into big trouble.
  • Sleeping with co-workers is frowned upon.  Especially when they are your supervisor.
  • People do go out and drink to drown their sorrows… But not that late and not every night.  Especially not on nights where your pager might go off.  Personally, I prefer drowning my sorrows with food or coffee… You can do that whenever.
  • It is just ridiculous that so much bad stuff would happen to a person or group of people.
  • Surgeons do not generally get that emotionally involved in the lives of their patients. There are limits.  It is good to care, but it is bad to become so involved you cause harm.
  • One does not care for their own relatives while they are in the hospital.
  • I don’t know anyone who would wear roller shoes to get around the hospital (though if I did, they would be awesome).
  • You compete, but things can’t be that cut throat.  You need your fellow residents to survive (I guess their friendships aren’t that unrealistic).
  • You rarely, if ever have enough time to eat a leisurely cafeteria/hallway/coma guy room lunch.  Most days, you do well to have lunch.
  • You can’t just hang out in a patient room and eat lunch while they lay there in a coma.
  • In med school, we sat on the floor in the locker room. Now I hide in the resident’s room. But never did I ever have time to have a prolonged lunch and hang out with coma guy. Image from wikia.org.

  • Not answering your pager is bad.
  • Ignoring patient wishes and requests and going behind people’s backs is bad.  And can get you in big trouble.
  • You can’t just not show up to work.  And the entire hospital full of nurses can’t strike simultaneously.  That would be dangerous.
  • Surgeons do not run the emergency room.  Despite how it appears on the show.  They are consultants.  They consult.  And do traumas.  That is all.
  • People don’t use the word stat that many times in the run of the day.  We speak like humans.  I swear.

I could go on and on.  As much as the show angers me, I keep watching it.  Some sort of strange solidarity because I followed it for so long.  Since it was less bad and less soap opera-ish.  I cry pretty much every episode.  I get ticked off at the errors in pretty much every episode.  Funny how that works.

I do love that recently they seem to mock the fact every once in awhile things are kind of ridiculous.

I also like the start and end of episode monologues.  Even though other shows copy it and it is kind of melodramatic.

Image from tumblr.com.

I am glad real life isn’t like that.  I am also glad my life is straying away from some of the similarities too.

Some people you just want to kick in the teeth

Last night/this morning, I finished my last general surgery call shift.

I classify it as a win in my books.  I survived.  And, to quote Patrick’s grandmother, “I didn’t know if I would ever make it.”

This was probably one of my better calls.  Aside from me forgetting my phone at home in the morning and trying to stalk down Patrick to get it back (iPhone=brain). It was the best call for sleep for sure.  I got a few decent chunks of sleep time. I had a few sick patients, but they were all stable by midnight or so.  It was steady all day up to that point, but from then on, just the odd call and assessment.

The nurses at the hospital I work at are really good.  The majority have been around for awhile.  They have good common sense.  They care about the patients.  They help me out a ton. In fact, I think I learned as much from the nurses while working the floors as I did the other residents and attendings.  Because the nurses are so awesome, there are minimal really silly calls for trivial issues.  I am so grateful for them and the work they do.

The thing is, there are some things that you always have to call someone about.  Because it is safer to do so than to not do so.  Things that are life threatening… You know, chest pain, fevers, new shortness of breath, excessive vomiting, etc.

This is where I got bitter last night.  And similar events have happened in the past.

I got called.  Out of a dead sleep at 3am to go see a patient with chest pain.  Perfectly reasonable.  I was already on my way out of bed as I heard the words.

I ordered the routine bloodwork and ECG and headed to the floor.

There, I was greeted by two of the staff who explained to me the patient is on high dose narcotics at home, is angry because we aren’t giving them more and when they were told this promptly started to complain of chest pain.

Suspicious.

But still, you just never know.  Bad stuff happens.

So, I go in to see the person.  They look comfy.  They don’t look sick.  Their vital signs were better than mine.

They give a story of having chest pain for the entire day and night.  It got worse a few hours ago.  The nurses are withholding pain medications.  Now, the person can’t move that side because the pain is so bad (as they move said side to demonstrate).  And the story kept changing.  And was inconsistent with most pain, except maybe post-op pain, but even that was a bit dicey.

Their ECG was normal.  Their bloodwork was normal.

So, I had the whole, it doesn’t look like anything life threatening talk with them.  And they asked for more pain medication in addition to the additional stuff that I just gave them.  I questioned this, as they had just said the pain was subsiding.  To this they said they could feel that it would come back.  I said to let the staff know if it did.

I am all about helping people.  And good pain control.  And giving people the benefit of the doubt.  But nothing makes me want to punch a person in the face more than when they are clearly trying to manipulate me and they do it in the middle of the night with a complaint that could be really serious.

I had someone else a few weeks ago who was being super rude to all of the nurses and roommates and started complaining about coughing up blood in the middle of the night.  Same sort of deal.  They did cough up a bit of blood.  The also had a nosebleed earlier in the day from pulling out their NG tube earlier in the day.  But, they did that earlier, but chose to point it out in the middle of the night when they were starting to be ignored.  I ended up getting stuck there for an hour debating the reasons why medications are sometimes given late and why we won’t give him more benzos and the like.  Really nothing to do about the mysterious blood.

I had someone else who every time we have tried to send them home, they present with a new problem that precludes discharge.  Pain, a new rash, dizzy spells.  They are genuinely sick.  But they also lean towards the dramatic.  It gets frustrating.  I just want to see them get well and go home.  Partly because it gets tiring for us getting called to assess and making arrangements just to have them changed.  But also because sometimes the best thing for people is to not be in the hospital.

I probably sound heartless.  I love people.  I love my job.  I enjoy taking care of people.  But, nothing is more annoying than people who take advantage of the system or who manipulate you.  Especially in the middle of the night.  When other people are actually sick (or you are trying to sleep).

Some people have genuine issues both with their mental or physical health and can come off as manipulative.  I take them seriously.  I investigate appropriately.   Except sometimes it is hard because they don’t give you much to go on.  Or it is clear that things aren’t as they say.   Then, I kind of secretly want to punch them in the face.  Especially when I am in the midst of getting pages about people with more pressing issues.  Or when nursing staff are being taken away from sicker people.  Or when we are all being abused.

There is an element of common sense here.  Some people don’t seem to have it.  And I suck at being a jerk.  So, often I still get caught up with these people until I get so annoyed or confirmed that they are being manipulative or drug seeking to talk them down.  I am getting better at judging this and approaching it.  I just don’t like to be mean.  So, I try to educate.  It takes longer.  It works most of the time.  It doesn’t mean I still don’t want to kick some people in the teeth.

I guess such is life.  There are always those people you want to kick in the teeth.  And it is most often at a time when you don’t have the time to deal with it.  It amazes me how self centered we as people (on both sides) can be… Me for wanting sleep or to deal with people with problems I need to fix and them for, well seeking attention for problems that, at least from the outside, can seem trivial (though for the person they can be significant).

But, yay!  I survived Gen Surg call.  And I didn’t kill anyone… Literally or figuratively.

Any job in the world…

I recently saw the question somewhere “if you could have any job in the world (and be fully qualified to do said job) right now, what would it be?”  It got me thinking.

So, I did what I do when anything gets me thinking.  I asked Patrick.  He wasn’t entirely sure.  Maybe likely actually teaching, but maybe journalism or something.

The thing that blew my mind was that I am actually doing that job (sort of) and am at least on my way to being fully qualified to do that job.

Actually, at this moment, as I sit in the hospital in hour 13 of 24 hour weekend surgery call, I question that a little. But really, even now I am mostly in my element.

If I could do anything in the whole world, I am pretty sure I would still do medicine.  Even despite the fact that I love to write and teach and such.  I feel like medicine gives me that and more.  And yes, I think I would still do rad onc.  And I would want to be doing it in combination with doing some palliative care.  An ideal split between the two would be awesome, but even just doing some part time coverage of a hospice would be amazing.

Obviously, I would love to be done with the whole residency thing.  I mean, it is a great learning on the other side, it seems.  The grass on my side is quite alright, though.

Nonetheless, I am working towards my happy place.  And realistically so is Patrick (at least he likely is).  I am glad we both are.  I think it would be just dreadful to be in a place where everything I was doing as not satisfying and nowhere near where I want to be.  I meet people who regret their choices and seem very unhappy every day.  It must be miserable.

I remember having a high school physics teacher (who was a touch on the crazy side with his handy dandy protractor and such) who told me one day that he became a teacher because he didn’t know what else to do with his physics degree.  Had he known about what became my undergrad degree (Nuc Med), he might have done that and enjoyed it more.

I also remember doing clinic with a very old pediatrician who was amazing at his job.  He is kind of a guru in his field.  We all respect him immensely.  At the end of clinic, he asked me what I wanted to be when I grew up.  I told him.  He asked all about it and my reasoning.  Then, he looked at me and said if he could go back 50 years, he would have done what I am doing.  I asked why.  He said that he picked something that was great and he would like, but really, he didn’t think he was smart enough (totally wrong) to do the other field, didn’t want to move to train and when he realized he could, it was too late.  He enjoyed his career.  His life is fulfilled.  But there has always been a piece of him that wondered “what if?”

Sometimes, I wonder if I will look back and wonder “what if?”  But I don’t think so.  At least not to the point where I think I would be unhappy.  It is a scary thought in some ways.

The good thing is that your job or where you live is not the key to life.  And you can make happiness as much as you can find it.  True happiness and satisfaction comes from so many places, namely God.

I may not be in my happy place (work-wise) yet, but I am getting there.  And grateful that I am on my way.  And that I know where that place is unlike many people in my age bracket.  Plus, the way to my true happy place is pretty darn happy most of the time, I must say.

This reminds me of a delightful Proclaimers song that I love to sing…

Body Balance

Sometimes it amazes me how our bodies adapt to things.  How we can tolerate so much and yet sometimes the simplest change can throw us for a loop.

Today, we took a 10lb tumor (note, this is larger than our cat in mass) out of someone’s belly.  They had no symptoms except a bit of an asymmetric gut.

Last week, we had a patient with several enterocutaneous fistulas (their bowels open to skin).  They have a relatively normal life even though most of what they take by mouth comes out of their holes in their belly.

On the other hand, I watched someone die from liver failure after getting an appendectomy.  They had underlying severe liver disease and the trauma of surgery threw off the balance they had been maintaing in their body.

I have also given handover that all of my patients were stable and then an hour after I went home, one crashed and had a pulseless arrest.  They died from a sudden rupture of a vessel unrelated to what had been done to them previously.

Sometimes a seemingly simple procedure leads to complications of epic proportions.  Other times, a complex and potentially deadly procedure has excellent results and uneventful recoveries.

I have to maintain a balance of just enough sleep to avoid migraines.  Too many late nights or late mornings kills my head.  Same thing with coffee.  It feels like a tightrope, but sometimes the head explodes when I do everything right.  Other times I can work multiple call shifts and do relatively okay.

The body is an amazing, yet puzzling thing.

Burning flesh and other medicine related stenches

Today, I was in the breast OR assisting in some relatively clean and quick lumpectomies and mastectomies.  For me, it is a great learning opportunity, as I will see some similar women for consultation for radiation in the future.

During our last surgery, the smoke evaporator got plugged with a fat chunk and thus, when we used the cautery, the odor of burning flesh was a bit stronger than usual.  It was cleared quickly because people are not fans of operating with the burnt flesh smoke in the room… Kind of gross and like smoking can increase lung cancer risk with long term exposure.  All seemed to be well.

I left the OR and went back to my office to work on a presentation.  All I could smell was burning flesh.  The smell stuck with me until pretty much when I left work about 3 hours later.

It made me think of five other smells that really linger and are rather disgusting that we encounter in medicine.

Melena.  This is poop that contains partially digested blood.  It is black, tarry and has a stench that can be picked up for a disturbingly large radius.  It always smells that gross.  Once you smell it once, you always recognize it.

Formaldehyde.  The stuff may preserve dead bodies and organs and such, but I swear it also preserves your nose hairs.  When I was doing neuroanatomy, Patrick would complain that I came home smelling like brains.  When I was doing anatomy and pathology, I was relatively convinced that I always smelled formaldehyde.  I would question if I somehow got some on my hands or that I was eating it.  Everything smelled like formaldehyde. It was awful.

Anaerobes in pus.  There is something about bugs that don’t need oxygen to survive and the disgustingness of pus that is always extra nasty and distinct.  I was in on a surgery to clear out some liver and intrabdominal abscesses, one of which communicated with the large bowel (of note, this was one of the most disgusting surgeries I have ever been in).  When we broke into the first abscess a strange smell that was kind of like a cross between poop, onion soup and pus filled the room.  I smelled that abscess well into the night.

Birth.  It is not the worst smell by any means, but it is indeed distinct.  Every delivery I have been to has a similar smell that I have labeled as birth.  It isn’t too bad… Except at 4am when you are already nauseous from being tired.

Image from anguishedrepose.wordpress.com.

Unwashed, unkempt person.  Often this is by no fault of the person in question, but a result of significant disability with no help or poor social circumstances.  But, sometimes I have to get uncomfortably close to an individual who hasn’t bathed voluntarily or not for a long time.  This, mixed with stale cigarette smoke is another smell that seems to linger on me even after leaving the scene and stands out as a similar experience every time.

There are some odors that do not sit well with people.  I am pretty much certain these are odors that do not sit well with anyone, but are necessary evils when working in the hospital.

What are some smells you just can’t stand or that stick with you in a not welcome way?