Life's little truths

This isn't mine, but I wish it were...

It's drawing near...

The end of surgery! (and third year)

Surgery's kind of a mixed bag in that we have a pretty slack rotation as far as surgery rotations go, but apparently an even *more* slackass group, so we keep getting in massive amounts of trouble with no conceivable way to end it since as the slackers keep slacking, eventually everyone sort of gets a "f- it; why am I doing the scutwork of two people when you're at home doing nothing" sort of attitude which compounds the slacking which compounds the trouble.

I feel the students' guide to slacking is to not slack in ways that screw over other students or sticks them with excessive amounts of work in your absence. Otherwise, slack at your own risk. If not, the whole group dynamic changes and people get angry, bitter, and defensive. I feel a lot of this is also a function of simply having too many students on this rotation. The statistical likelihood of shameless slackery goes up simply with the number of people, plus since there is an overflow of students that lessens the workload, it creates an impression that you can do *nothing* and others will pick up the slack. This is partially true, but creates a tremendous amount of resentment.

If you are going to slack, the worst way to do it is the slack-and-schmooze. This is a brilliant technique wherein your colleagues are left with thankless scutwork while you flash the glistening smile at the attendings of someone that's racked up an adequate amount of sleep. To be fair, this technique seems to frequently pay off gradewise (leading to a similar phenomenon observed in residents), but your classmates will want to kill you even more than if you were the simple shameless slacker that could not be less interested in ________ rotation, and has no problem showing it. Be advised.

Lest anyone get the idea that I'm claiming to be a good little worker bee when half this blog has been dedicated to my various non-medicine related exploits, I'm not. I tend to refer to myself as a lazy buttmunch with frequency, but moderation people; jesus.

Anyway, so that's that bit. Otherwise, surgery's mixed on its own because as a lazy buttmunch, I detest long hours, and in particular, early mornings, which surgery has in abundance. I'm also fidgety and get hot easily, both of which are not fantastic qualities when you're scrubbed into surgery leaning over a heated air cushion and not allowed to touch your face. On the other hand, you get to do what I generally associate with "medicine" such as "Hear patient's complaint. Use prohibitively expensive education (or Wikipedia) to diagnose complaint. Remove complaint. Hope removal of complaint doesn't lead to minor complications such as wound site irritation or massive blood loss. Discharge happier patient sans complaint. Make bed of money and roll around in it."

Okay, not that last part. For anyone reading this that thinks becoming an MD is an efficient, effective way to make money, that is the same logic as deciding to get a piece of cake by working your way up at Duncan Hines starting as a janitor and eventually buying stock in the company fifteen years later so you can sell it to buy cake.

I'm also finding kind of a mixed bag on the whole surgeon personality thing, which I was initially warned about and expected to be far worse than it was. I've found surgery people more prone to tantrums than your average other-doc and during conference, they're absolutely brutal to each other, but they also seem to possess far less soul-crushing existential angst than other branches of medicine indicating a certain level of happiness. On an individual basis too, I've found most of them to be fairly friendly and nice to students (with a few rather drastic exceptions). So that's cool. Procedures are also interesting. I'm also learning a surprising amount of real medicine because diagnosis is key when screwing up leads to the definitive "uh oh" moment of opening the wrong thing. So they aren't the mindless scalpel jockeys of legend either.

Surgery possesses some amazing gadgetry too, even at county hospital level, which I assume is largely around based on surgeon-tantrums so maybe they have a purpose. For every engineering inconvenience in the human body, there is a tool that's made to deal with it. Wanna remove a section of cancerous bowel and snap the healthy ends back together in such a way that gets you out in time for lunch AND keeps the patient from having to carry their waste in a bag for the rest of their life? There's an app for that. Wanna see where that obstruction is without having to saw through that large important artery? No problemo. So far the only drawback other than the huge cost of manufacturing the most specific articles on the planet (this tool is made to see around gallbladders!) is that then you have to learn the names of all of it. Or if you're a med student, the suture scissors, since that's generally what your tool is. And we take it seriously too.

I'm on ENT now, which is particularly nice, and am almost comfortable enough with the staff to ask them to clean my ears, since after a few patients and the standard procedures of doing a standard ear exam on people without significant symptoms, going "hmm", and still pulling out giant disgusting gobs of crap, I'm paranoid. Though I suspect the root of my gradual hearing loss is far more likely embedded in the fact that I'm in physical and emotional connection with my ipod every second that I'm not at the hospital or asleep, as it protects me from having to talk to people on the subway.

ENT is also proving more interesting than I expected. Lots of allergies and sinus infections naturally, but also some crazy frigging tumors.

Still, pathology calls. There was some downtime in SICU last week that coincided with helping out in the gross lab and an autopsy so I got to make productive use of the time and got to practice some suturing where I can't do damage, which enhances my confidence greatly. When I wasn't fixing the computer.

Lemme just take this opportunity to again rail at frigging virus makers, since the SICU computer got hit with an almost exact variant of the virus I had, which is the only reason I knew half where to start with it having dedicated an entire Saturday to it previously (thanks, jackasses!). So not only are they stealing your credit card information, they're also trying to hinder medical care to your loved ones. Please remember that the next time you happen to catch yourself in a dark alley with one of them.

Speaking of peaceful hippie love, I went to Woodstock and the nearby lighthouse this past weekend so I could give my mom an urban escape for her birthday. I would highly recommend that for anyone who needs a break. What I would not recommend is what I did last year, which is using Woodstock as a staging ground to get lost in the Catskills at night, but I managed to refrain from doing so this time around.

Bedtime. Tonsillectomy in the morning, so I can finally see what was done to me as a child...

So I'm on teams now...

Which may explain a thing or two... the skinny, before having to get to bed late (the horror)...

6 AM to 5-6PM.
Run in the park.
Watch Inuyasha (I know it's marketed to 8 year old Japanese girls; I can't help it).
Bed.

Oh, and there was the sake bombing Saturday night, but ya know...

This week I have two straight weeks of teams with a Saturday call in the middle. I would be more pissed off about it (though I've been griping about it for a while now), but we're only on call every 9 days versus the every 3-4 days at some hospitals, so it's hard to be *too* upset, and I got this last beautiful weekend off AND was post call on Friday, so kind of a three day weekend.

Weirdly, the difference between a good surgery and a bad surgery lies in the people you're with. First two lap choles, awesome, I am a camera-holding goddess; circulating nurse being nice; good procedures. Exact same procedure; different doc; I am worthless at everything, the OR nurse hates students, and any med student holding a camera is trying to make some hideous Cloverfield/Blair Witch crossover. I also almost got kicked in the head by the patient. Fun for all.

Also, while I'm on the hardest team now, I like the chief and have scrubbed in with him before and he (gasp) likes to teach. Let's see what tomorrow brings.

Anti Powerpoint Rebellion

Though apparently I'm late on the bandwagon and there's already a group of anti-establishment Luddites that have taken this position, but I'm over PowerPoint. This hit me last night.

I'm not saying PowerPoint doesn't have its uses, like all three of them. As someone that's infatuated with pathology, you need PowerPoint (or some kind of visual projection device) to teach it. Diagrams are also useful, particularly in surgery, where they tend to do procedures that connect stuff to other stuff you wouldn't necessarily expect, and you kind of need a diagram representation of what GI anatomy looks like after you've put in Tivo and a hot tub. Or something. So yeah, if you need something that isn't "words", hooray for PowerPoint.

I was kind of indifferent to PowerPoint for a long time. I laughed when people put in the "funny" slide or the unnecessary slide effect, as you're supposed to, and the really bad PowerPoint presentations stand out as really bad PowerPoint presentations, so I hadn't really chalked them up to the program, but to people's inability to understand the concept of margins, grammar, or choosing colors that don't provoke seizures, and that's valid.

But two things happened yesterday. One, it was conference day, which pretty much means around 7 hours of PowerPoint. Some lecturers are good; some are not. But I realized that the second they dimmed the lights to put up the projections, I had a Pavlovian reaction. I pulled out my Surgical Recall to study.

So essentially, I don't mind PowerPoint because it offers me the opportunity for self-directed study unmolested without the distraction of an engaging or novel lecture. And books tend to be more significantly higher yield, probably because they're not in PowerPoint format. And they're in normal English because the authors presumably have not been doing language gymnastics to avoid direct plagiarism. And I realized the only way to actually pull me OUT of reading my book is to have a lecturer that is either distractingly good or distractingly bad. But most fall under the "okay" line of droning information that is already on their slides with topics they know well, but are no longer capable of presenting in an interesting fashion.

Then I watched one of the really good, extremely knowledgeable residents get the crap pimped out of her on topics that were already later addressed in her presentation, which in fairness, wasn't bad. But you have no flexibility in the direction you're going with PowerPoint because it's already on the slides. And then if the attendings toss you in another direction by ripping you apart with questions, you're still left having to come back to your presentation and plod through slides they may have just explained to make a point, at which point you just kind of stare blankly at the screen, glance at the audience, say "uhhh" and then flip quickly past an hour's work, most of which probably consisted of spacing out the bullets and changing the fonts. Your audience is bored, you've lost your mojo, and more importantly, an hour of your life you will never ever get back.

Everyone thinks about the bad PowerPoint lectures because they're hilarious. But then I thought long and hard about the last GOOD lectures I've had. I've had plenty of perfectly functional decent lectures, including by other students, even when I was forced to pay attention, because text on screen is still text with information, even if it's a wildly inefficient way to get it.

But even this rotation, the GOOD lectures? Half of them were rounding with attendings. The SICU chief who kept vividly maiming our patients when we strayed in the wrong direction: "After spending four hours convincing Anesthesia to actually let you do this procedure, the patient codes on the table. They're resuscitated AGAIN. Systolic pressure is 50". "Uhhh... well, I'd order..." "40." "I'd explore the..." "30." "AHHHHHHH!!!" "Patient begins pouring feces out of the incision site." "AHHHHH!!! Is that a real thing???? Yes?? AHHHHHHHHH!!!"

The lectures with our attending that tells dirty jokes and pimps us... the impromptu question reviews, even when I think they aren't going to be relevant because they're surgical resident question reviews and I haven't studied adrenal anatomy in 8 months. Almost none have used PowerPoint. The ones that do have either been almost exclusively image-oriented or the speaker has barely referenced them and flips through them in the middle of an interesting lecture because a PowerPoint presentation was required or he doesn't have a pen that writes well on the back of his hand. (I'd make one of many easy cracks at Sarah Palin here, but since I totally do that too, I can't.)

And why do the funny effects or that humorous cartoon, or the serene picture of the beach entertain us? Because PowerPoint lectures are so mindnumbing that we need the emotional break from wanting to kill ourselves.

Which finally brings me to my second point. I had to present an excruciating article for surgery today and was up late doing it (because I was late in a lecture and spent a good part of the day listening to an attending bitch and moan about medical students not 'being around' because we're unreasonably 'post 24 hour weekend call' or 'in mandatory conference'). The article was almost exclusively statistical analysis on other statistical values about a topic that wasn't really easy when you stripped it to the original condition, and because I'm not a statistician (nor am I good at arithmetic), I had to Wiki half the terms in the freaking thing.

So I *finally* was able to understand the article, its point, and the original topic it addressed, and interpret the numbers.

But THEN I *still* had the task of taking all the information I had in my head AND the organization and logical follow through, and then turn it into a deadpan samey boring ass PowerPoint presentation despite having no idea which way the attendings would direct it. Plus doing PowerPoints gives me complete mental constipation while I struggle to elaborate on bullet points without reading text off the slide like the listeners are illiterate children rather than board certified freaking surgeons. In addition, the article was virtually incapable of being made interesting by anyone nor to anyone, and the only way you can make it less interesting is by taking all those statistics and copying them onto a PowerPoint slide.

So I kind of rebelled. I put together like 5 slides with the main points on them (particularly since the entire point of the article is summarized neatly in the title and the entire paper is merely justifying why they aren't full of crap) and just talked about it, summarizing the key findings without blasting numbers on a screen at 7 in the morning, and pretty much ignored my own slides. I think I was stuttering a bit because I'd gotten four hours of sleep and was presenting to a group of attendings without the mental crutch, but no one seemed pissed, so who knows.

Surgical call...

sucked.

How can I be on surgical call for over 24 hours, two of which we were allowed to sleep, be busy for most of the night, and not see any... surgeries? Honestly, I barely know what was wrong with half the patients, though I certainly know what their labs were. OB-Gyn call could suck in that it was long and hard and you got scutted a lot and you were the definitive vitals/labs bitch, but all that stuff was punctuated with somewhere between 1 and 7 deliveries/c-sections a night which they insisted students be in on, so calling it "OB Call" was as advertised.

But guys, seriously. It's called "COMPUTERIZED CHARTING". For the love of all that is good and beautiful in this world, institute a program with more patient-organizing power than Office 97. That goes for about three quarters of the hospitals in this city. Why progress notes are still being scrawled illegibly on easily lost or damaged charts that have to be fought over by all the attendings, residents, medical students, and nurses who need them at the exact same critical times escapes me. And med lists... freaking... list every single medication a patient is *currently on*, changes to medication with date/time, and electronically attach that data to the patient's name. And to add an extra stage of programming that could be done by a precocious 12 year old with a Warcraft habit and his own 4chan meme, throw up a caution if any drug is prescribed to which a patient has an allergy or if there's a hazardous drug interaction. No, have some on the paper copy of the medlists, some on the computer, some in a different part of the chart (which you often can't check because the nurses, who have to dispense the medications, understandably need that chart as much if not more than you do), confirm by occasionally having medical students check to see what's in the IVs. WTF?

I know this *can* be done, because it *has* been done. Not only is the lack of electronic charting really irritating to medical students (and everyone else) that then has to dedicate hours and hours to rewriting information that is in one place into other places (if they can read it) or hilariously, *typing* information from one excel list to another, but it's unnecessarily hazardous.

Anyway. On the plus side, all the people in surgery I've met so far since I've been on surgery have been really nice, which has been an unexpected surprise. Surgical staff is not commonly associated with uh... social grace, or a particular love of our grimy, wound-contaminating, instrument-dropping ilk so not getting yelled at has been a bonus and I really like the main attending we've been introduced to, so not all bad.

And early in the night, the resident was showing us some bedside procedures which I didn't get in internal medicine, which I think is where I was supposed to. I got to drop an NG tube in ED (which was awesome), but last night I did get to listen for the gurgle to ensure proper placement, which was loud enough to be startling, so I'm finally getting some use out of my stethoscope beyond putting it on a patient's chest, listening intently, frowning, and then lying when the attending asks me if I can hear the murmur. At least I always remember to have the earpieces in.

Surgery!

No pictures in *this* one, guys!

So, on Monday I was allowed into surgery, not scrubbed of course, but in. I got there at 6:30 am (Aiiieeeeee!!!!) so I could oversee the entire process including the preop. I was given a temporary locker in the nurse's locker room, where I could change into the surgical scrubs, a surgical cap (which I already had), and a pair of booties over my shoes.

The patient was already in the pre-op room, gowned and capped, but wide awake.

I talked to the patient for a good long time, who had avascular necrosis (this is where the blood supply is interrupted or terminated, causing death of the tissue, in this case, bone) causing a need for a knee replacement. The location of the necrosis was pretty rare, and the doctor had shown me an article on it at the office when he initially saw the patient.

After a while, the anesthesiologist showed up and immediately began drilling me on anatomy as he was doing a nerve block. Whoops!!! I did all right on the order of vessels through the femoral triangle, but I need to do the innervations below the knee better, because I completely screwed up what the femoral nerve does below the need (just provides sensation to the strip of skin down the front of the shin), so sorry SGU!!! I was studying for biochem at the time I was supposed to be refocusing on lower limb!

Though I initially got flustered at having questions shot at me and struggled to find the answers to questions I actually, for the most part knew, I was grateful for it as well. The guy was really nice and it gives me some preparation for my rotations and residency when people, that will probably be far less nice, will be shooting questions at me left and right, so I like being quizzed. It's harder than I would have thought. I also found myself overcompensating for what I don't know by overexplaining the stuff I do know (like where a femoral hernia goes), so I'll watch that.

Over the scrub sink, I grabbed my mask (no gloves), and wandered into the OR suite, watchng them set up. It's fun to see the sterile versus nonsterile, and I watched the scrub tech (sterile) scrub up while the circulating nurse (who runs the show and isn't sterile), opened up packages, being very careful not to touch the sterile stuff with in. It's like an antibacterial little dance.

They brought the patient in, swapped him/her (HIPAA rules, no identifying information) to the operating table and chose ME to try to wheel the large gurney out the door by myself. I've operated these things a dozen times, but for some reason, when you're trying to force one out a door that's not supposed to stay open for any length of time, you do stupid things like get the doorknob stuck through the rail. D'oh!

But no nasty comments from anyone there, fortunately, though I did get told to close the door where upon coming back (having been let back through the doors to the surgical wing by the surgeon, who was arriving in time to watch me lock myself out), I went through the wrong door (the one I'd gone out). D'oh again!!! Heh heh. Hey, first time in surgery; cut me some slack.

The anesthesiologist gestured for me to stand next to him, and answered a lot of my questions as I leaned over to see. There's a drape that separates the nonsterile head of the patient (and anesthesiologist) from the sterile body where the surgeon and scrub tech are working. I was constantly worried whether I was in the anesthesiologist's way, but he just chuckled and said "Just don't lean on the drape or touch anything blue and you'll be fine".

The surgery was pretty cool. There are so many individual important orthopedic tools, sizing, and such, plus the surgery itself, as far as motion is concerned, is pretty violent, with hammering and drilling and all, but with the tourniquet and suction, it was virtually bloodless, which I hadn't been expecting. What was really strange was when I was watching the patient's knee, which was completely open, and I could see both the end of the femur and the head of the tibia, with the kneecap pushed out of the way, the patient, due to the type of anesthesia, wasn't on a breathing tube and was snoring away in happy slumber! Bizarre! But cool.

Everything was closed up, with the surgeon having a much greater aptitude than I have for stitching (I really need to work on my stitches further; I'm not great, though I've only worked on cadavers). I went with the patient, who, upon waking, was feeling no pain, and talked to him/her for quite a while before wandering off to see if there was any place I was needed. I ended up hanging out in the surgical lounge with a couple of the anesthesiologists, the surgeon, and the sales rep from the company that makes the knee replacements.

During replacements, a rep from the company often comes, since that representative is an expert in the materials used, oversees the operation (though not sterile), and helps with things like sizing the implant. This makes talking to the reps fascinating since they've seen it all and really know the product as well as the operation, and since they aren't having to scrub in and do the pre-op medical stuff, if they're interested in talking (and this guy was), they have the time to tell you all sorts of cool stuff.

I didn't do the preop on the second patient, and got into the OR when they were doing the first incision. I stood next to the rep, which gave me a really good view of the whole procedure, which they were doing with a "uni", an implant they do for the medial (inside) of the knee if the outside is fine and all the ligaments are intact, so that the entire knee joint isn't loss, and the scar is smaller.

The rep answered a bunch more of my questions, including what all those scary tools were, and again, awesome experience.

After that, it was lunch time! Yummy! Drumsticks anyone?