Cut On The Dotted Line

For someone who spends as much time communicating as I do, I’m obviously still not very good at it.

Since between work and Pascha services this week I don’t have much time, let me, as the fastest way of saying what I really think about Mormonism, refer you to a post I made this spring, back when Romney was a viable contender. You can find it right here. Basically, I conclude that Mormonism is a false religion, just as much originated by Satan as Islam is, in that he probably inspired two men (Mohammed and Joseph Smith) to write blasphemous lies against Jesus. Mormonism, unlike true Christianity, does not regard Jesus as divine, the only-begotten, unique Son of God. Mormonism teaches that God was once a human, and that all humans (or at least all males) can become gods in their own private universes, peopled by the offspring of their subservient wives (so yes, Mormonism, like other false religions, tramples on women, and, unlike Christianity, regards them as lower in kind than men).

Regarding polygamy, I agree that it’s illegal in America, and that even the biblical patriarchs limited themselves to two wives, and those of an age to consent.

What I was trying to say about the FLDS branch of Mormonism is that 1) I think most Americans’ visceral reaction to them is based on lifestyle choices that have nothing to do with polygamy, but which do present a glaring challenge to the culture of hedonism and free sex that prevails in America today; and 2) I respect groups which hold to the original tradition when it’s not politically correct to do so. The mainstream LDS church threw out Joseph Smith’s original teaching on polygamy because it made their life easier to do so. The FLDS hold onto it; even though that may involve brainwashing women, it’s at least the original form of Mormonism. Similarly, I respect “radical” Muslims more than “moderate” Muslims, because I think the radical Muslims understand and obey the original commands of Mohammed (kill the unbelievers until they submit to you, make no friends with Jews or Christians) better than the watered-down, secularized, moderate Muslims. That doesn’t mean that I approve of suicide bombers; I simply think they’re acting on the logical conclusions of their beliefs.

Does that help at all? Maybe I should also mention that in my personal beliefs, I try to stick to the Bible exactly as God gave it, without making alterations for modern sensibilities. God created the world out of nothing, in the space of six days, and all very good, until it was marred by man’s sin and the entry of death. God condemns sinners to hell in the next life because of their infinite crimes against him, and he is righteous and loving to do so (we can take this up in a later post). God offers free forgiveness and eternal life to all who confess that they have broken his laws, and accept his merciful gift in Christ, who died for us and rose from the dead on the third day, and sits in heaven until his kingdom is established through the whole world, and all nations kneel down and worship him. And along the way, women should submit to their husbands, men should have one wife and be faithful to her, and Christians ought to love their neighbors as much as they love themselves. This is absolutely true, and I make no apology for any of it, except to say that I wrote it as forcefully and bluntly as possible in order to parallel my wild statements about Islam and Mormonism.

They and I are at least in agreement about the existence of absolute truth and the extreme importance of finding it out; just as I had more in common, regarding modest clothes, and avoidance of wild parties, and chastity, and taking time out from studying for religious observances, with the Muslim girls in medical school, than with the nominal Christians.

I look forward to reading your comments.  :)  And I guess I had better also put out an apology in case any of the above is needlessly offensive, as I may not have time to answer comments till late in the day. I don’t mean to be insulting, but to state the truth as I know it, forcefully. The lateness of the hour may make some phrases ill-judged.

I’ve figured out what my problem is: I don’t have any common sense.

There was a patient today, and I just couldn’t get it right. The only good thing about the whole humiliating episode was that I erred on the side of overestimating the patient’s illness, not underestimating it. (Humiliating as in, now anyone in the hospital who had any doubts about my competency/intelligence/character has had them answered - not in my favor; ok, I guess the entire hospital wasn’t paying attention, but it feels like most of the surgery residents were.) I was starting to feel the slightest bit hopeful about next year, but not any more. Actually, I’m not so worried about myself, as about the people who will be getting called by me, since I’m clearly no good at assessing situations.

Honestly. I messed up, and the only conclusion I can come to is that I have no common sense. And I don’t know where to get any. You would think, if it came with experience, after ten months I would start to be able to at least add two and two, or simple things like that. You can’t get it out of books, because I’ve been studying with unheard of diligence for the last two months, and it’s not doing me much practical good. It wouldn’t seem to come from anecdotes, because I’ve read a great many medical blogs and memoirs with enjoyment, and that doesn’t help either.

So what do I do? I don’t think I’ve made enough spectacular blunders to get fired, although that would certainly save both me and the attendings a lot of headaches next year. The only two practical things I can think of are: I didn’t keep my hands in my pockets, or my mouth closed; and, I should walk away for ten minutes and come back before making any conclusions. I’m reduced to formulas like this for at least reducing the impact of my lack of common sense. Maybe it’s just that I still need a lot more experience, which is definitely true, but the other interns don’t seem to make the same kind of mistakes I do. Like they were born with surgical intuition, and I wasn’t. . .

You know the reason everyone is really so rabid about the polygamists? It’s not just the matter of teenage mothers (who, after all, are a common enough phenomenon in this society; here, at least, they’re respected as legitimate, and the fathers are involved with their children).

No, it’s the women’s clothes. Modern Americans take one look at their appearance - which I would describe as graceful, elegant, sweeping, modest dresses and beautiful swept-up hair - and react viscerally, I believe because they’re convicted by this total contravention of modern society’s flagrant embrace of everything vulgar and obscene. It’s almost as though men think they have a right to see barely-clothed women, and are affronted by these women denying them that privilege; as though women think that they earn respect by flaunting their beauty in the eyes of all, and are defied by these women’s refusal to do that.

That, and the large families. In a society where a single child is pondered before years before being accepted, and where two children are an imposition, three unheard of (in the professional circles I seem to be in these days), the idea of having many children is shocking - the 400 kidnapped children (since I don’t see where the government gets the right to take all of them without specific evidence against everyone’s fathers) are described as a crowd of toddlers and 4-5 year olds running around under foot.

Plus, their rejection of the modern world. My friends talk as though it’s evil not to have TV and internet and cell phones. Who am I to talk, of course; but I think I can at least recognize the beauty and possible desirability of such a lifestyle (the Amish, for instance), while still choosing to use some of modern technology myself. So far, I’ve refrained from pointing out to my colleagues that I was raised without TV (although they may have figured that out from my profound pop culture illiteracy), and regard my cell phone as a necessary evil.

(I have previously described Mormonism as a heresy. But I respect the FLDS people for being consistent and true to the original spirit of Mormonism in spite of intense persecution.)

I betook myself to the Coptic Pascha evening service tonight after work. I missed Palm Sunday service through falling asleep post-call, and not being able to muster the energy to get myself out of bed after a 15min nap. So I felt bad about that, and I considered giving up on the enterprise of keeping Pascha and working 13-15hrs a day at the same time. But then there wouldn’t be an Easter that meant anything to me, and that would ruin the whole year, and that would be pretty bad.

So I dragged myself to church after work, not entirely thrilled about a 1hr round trip, and two hours of service (allowing for missing the first hour, and skipping the last 45min due to the sermon being entirely in Arabic).

Somebody please kick me the next time I consider missing Coptic church. I was so glad to be there. I didn’t know many of the people, and I didn’t have a service book. But we were praising God and commemorating Christ’s passion, and there is nothing better in the world.

Thine is the power, the glory, the blessing, and the majesty, forever, Amen.
       Emmanuel, our God and our King.
Thine is the power, the glory, the blessing, and the majesty, forever, Amen.
       My Lord Jesus Christ, my Good Savior.
           The Lord is my strength and my song, and has become my salvation.
Thine is the power, the glory, the blessing, and the majesty, forever, Amen.

The Copts are my identity, one of the only things about me that’s still the same at the end of this year. At that church, everything is right and in order.

(Man cannot live by bread alone; and neither can one get by entirely with Presbyterian church services, especially the strict ones. They’re missing something, like icons and incense and color and music. I should point that out to the elders of the church I’ve been going to. The reaction at least would be interesting.)

The other day I saw my first ED thoracotomy. For those of you who aren’t medically fluent, that means splitting someone’s chest open in the trauma bay of the ER in a usually doomed attempt to save their life by cross-clamping the aorta to prevent bleeding, and dealing with fatal holes in lungs and heart. The success rate if this is performed for penetrating trauma (gunshot, stab wound) is commonly reported as somewhere near 5%. Perhaps not that much, although we did recently have a guy be discharged less than a week later. The indications are few and far between: for blunt trauma (which means that the attempt will probably be worthless, since if the person is dying of a blunt chest trauma it implies a massive disruption of the aorta, or something else impossible to fix) it’s only strictly indicated the patient codes while being wheeled into the trauma bay, or shortly thereafter. For penetrating trauma, the rules are a little broader, involving loss of pulses anytime after the medics get there.

The trauma team was short-staffed. It was the kind of day where all the junior residents know they’re supposed to come and help if things get hairy and they can manage it. When the page went out, “trauma code, gunshot wound to chest, unknown male, intubating, eta 5 min,” we knew it was finally real. Our trauma center tends to do a lot of fake penetrating trauma: gsw to chest, really through the flesh of the shoulder; gsw to abdomen, a glancing blow across the flank; stab wound to chest, a 1cm flesh laceration; and so on; which are all billed as trauma codes, because they’re quote penetrating. But if this guy was getting intubated - that’s real. I was in the ER anyway seeing a flow of consults, and now I was just waiting for CTs to get done. I knew they wouldn’t happen while there was a trauma in the vicinity, so I had time to go see.

The trauma chief and intern always put on gowns, face shields, and shoe covers for these things, because you never know how much blood there will be. This time we all, including the attending, who rarely has to get his hands dirty, covered ourselves from head to toe in paper and plastic. The trauma bay looked more like an operating room than a space in the ER by the time the ambulance rolled up. The trama chief, who’s done this a couple times before and doesn’t really need instructions from the attending any more, was very organized, determined to avoid the kind of chaos that sometimes ensues when a trauma is halfway between nonsensical and deadly serious. He handed out orders: I’ve got the thoracotomy tray, you put in the left-sided chest tube, you do a cut-down and get access, you look for an ABG, you’ve got the airway, you help with the airway, keep xray out of here there’s no time for them.

One of the techs looked out the door as the ambulance rolled to a stop. “They’re doing chest compressions, guys,” he reported; and the chief broke the final seals on the sterile thoracotomy tray.

The medics wheeled in, transferring the patient onto our gurney, giving their meager report: gunshot wound, down for maybe twenty or thirty minutes by now, maybe more, pulses in the field, lost in transport, finally intubated a few minutes ago. Then there was a perfect storm of activity, but all in dead silence, because no one needed instructions, and we could all tell by the skin’s gradual transition from pink to grey that this story was not likely to have a good ending.

I think my mind did something funny, because I somehow didn’t even look until the chest was wide open and the chief had his hands deep inside, probing for the aorta to cross-clamp. Ok, so I had been assigned something else to do, but you would think I would look at the first time I’ve ever been present for this legendary maneuver.

It didn’t matter, in the end. The bullet had torn straight through the apex of the heart, shredding the muscle. A liter of blood and clots poured out when the chief had the chest open, and then the heart was loose and floppy in his hands. The hole was too big and ragged to do anything about, and there was no blood left inside to try to keep in, anyway. (Which makes me question the theory of his having had pulses until just before he arrived; I don’t see how he could have lived twenty minutes with that big a hole in his heart. Tamponade, maybe.) Somebody had good aim; unusually good aim; fatally good aim.

(The cops are kind of funny at these scenes. They hang around at the edge of the trauma bay, fascinating to us because maybe they know what happened, and we don’t, and most likely they’re going to arrest someone based on what our attending tells them. Then one of them steps forward as the assembled techs, nurses, and ER residents fade away, and asks, “Is he deceased, then?” And we all shrug, and I’m left to answer. “Yes sir, he’s dead.” His chest is gaping open and most of his blood is on the floor, there’s a tube in his throat that’s not connected to anything. Yes, he’s dead.)

Everyone else is gone now, and it’s just handful of surgery residents left standing in the blood and litter of papers on the floor. The man’s face is completely grey, a strange contrast to the blood scattered so liberally over the rest of his body, and indeed over us as well. Without a whole lot of conversation, the attending grimly motions us all over to the right side of the chest, determined to make sure that we all know what the aorta feels like when you’re hunting for it blind, arm reaching in past the elbow, the view obscured by the lungs being inflated by the ventilator, and no time to think. Based purely on feel, the chief had somehow separated the aorta from the heart above it, the esophagus beside it, and the spinal muscles behind it, and clamped it just above the diaphraghm. It felt strangely limp, unnaturally empty. For this guy it’s too late; but we’re not going to waste the opportunity, since nothing can hurt him any more, to learn things that could save someone else’s life in the future.

It was somehow not as dramatic as I’d expected, the actual event. Perhaps because the conclusion was so clear from the moment the medics walked in. Perhaps it would have been different if we’d really though there was a chance.

But it raised the same old questions for me: the chief tore this man’s chest open and plunged both arms in, recklessly dissecting down to the aorta. Will I ever be able to do this? Do I want to be the kind of person who can do this?

The chief said almost nothing, before, during, or after the incident. He’s grown a silent, protective face over the last year. I remember in July, his face used to give things away, and he would get hurt by it, when confronted by an attending in the OR or in M&M conference. Now his face is almost always the same, no matter what’s happening - years older and locked like a bank. He’s got two months to go on trauma; and that’s the only thing pulling him through; that, and his wife. So I think inside, things like this disturb him, too; but he doesn’t talk to us much about it anymore. Maybe his wife hears, but no one else.

I am so happy to be a surgery intern. I don’t know if I mentioned that lately. I am thrilled that I get to work with these patients, and no others, with these attendings, and no others. So what if I have to get to the hospital a couple hours before the sun rises; I’m there to see people with cholecystitis, and appendicitis, and aortic aneurysms, and cancer, and incarcerated hernias. Sooo much better than coming in later, and seeing people with hypertensive crises and strokes and weird metabolic disorders that got out of whack. These patients are all interesting, because they all have surgery in their past or near future - and it’s great.

Sometimes, now, I get home while there’s still light outside. Perhaps I should stop cursing daylight savings time. It is, after all, more valuable to have light for a walk when I get home, than light to see the highway in the morning.

My mother’s house is full of plants - flowering plants, and also those insanely annoying potted menaces which do nothing but grow leaves. The flowers I think I’ve always appreciated, but I could never see a point in keeping a plant which did nothing but grow green leaves.

I’ve broken down, and bought pansies to put outside my window. I can’t stand not to have some live flower closer than the trees and tulips in the neighbors’ yeards. I’m trying to hold off, but I foresee green potted menaces in the near future.

Because I was at the hospital late this afternoon (late as in, past civilian office hours), I got to see a complication in a patient our service operated on earlier in the month. It was the first time I’d ever seen or heard of, and it was a great experience to figure out what it was and then call the chief and treat it in the ER with him. Because we sent the patient straight home, the team members who weren’t in the hospital that late will never see it, and if things get busy this weekend, they may never even hear what happened.

There’s a rumor floating around that the ACGME (bureaucratic organization that regulates all residency programs) may be looking at imposing 60hrs/week rules. I sincerely hope that this is an urban legend, since I haven’t had anyone close to a program director verify it yet. . . but given the number of insane, counterproductive things that the government and other agencies are doing to the healthcare system, I could believe it.

All I can say is, I hope they wait till I finish residency to do that. If not, I think I would finally have a chance to practice civil disobedience, as I have always longed to, and flagrantly disobey the rules.

We barely have enough time right now. I know the chiefs who are graduating this year have expressed a great deal of angst about being the first class to go through completely under the 80hr rules. They have no idea how their skills will match up to the real world in July. They’ve said things about having less experience over all, feeling less confident than they think their predecessors a few years ago did. Maybe it’s just the usual nervousness before taking another big step. . . but maybe they’re on to something.

I can not imagine what we would do with further hour restrictions. We’re already limited to 12hr shifts. The only way to cut time down further would be to move to 8hr shifts - and then 2/3s of the residents (afternoon and evening shifts) would be simply wasting their time, being present in the hospital purely for coverage reasons, and the occasional emergency surgery, since most of the surgery action happens in the morning and early afternoon.

There’s a physical impossibility in here: surgeons do most of the things that medical doctors do - admit patients, round on them, order and evaluate tests, discuss the results and plans as a team - and in addition, we have a whole ‘nother day’s worth of work to do, in the OR. Doing 2x or 1.5x as much work as another specialist would do simply takes more time. I suppose we could also not round on patients before surgery, just catch up on them piecemeal between cases. But considering how many near-disasters have been staved off during morning pre-rounds, I can only conclude that patient care would suffer abysmally from such a change.

Somebody keep the ACGME tied up with some paperwork for the next 4 years, please.

Once again, more studying got done than my brain can really stand. Learned all kinds of things about the biliary tract, including, in detail, what to do if you injure the common bile duct during a laparoscopic cholecystectomy. Which is actually fairly irrelevant, since although I’m afraid such an event may be in my future (incidence stable at 0.5% for the last several years), hepatobiliary surgery has never crossed my mind as a specialty, so I am sure I will not be in a position to repair the injury adequately. The general tenor of the lengthy textbook discussion was, interspersed with detailed instructions on how to repair every variety of injury, admonitions to refer such patients very early on to a major center and an experienced hepatobiliary surgeon. So mainly I learned something else to try very hard not to do; of which I already had a long list.

I’m still not happy with my moral position during conversations which I disapprove of. But at least I resolved, again, to try very hard not to say anything I wouldn’t say if the subject of the conversation were in the room. Maybe I can’t help what other people say; but I don’t want to contribute.

I really love this type of patient conversation:
Me: “. . . So basically everything that brought you in to the hospital has been corrected, and you are ready to go home, although you do need to continue taking these medications.”
Patient: “Great, I feel fine, I was ready to get out of here yesterday. Let’s go.”
Spouse (with the most suspicious tone of voice you can imagine): “You’re not kicking him out of here again, are you? I’m sure he was deathly ill with this xyz the last time you discharged him, because he was sick immediately [although we didn't come back to the hospital or talk to any office staff for a month].”
Me: “Ma’am, I understand your concern, but I assure you that there were no signs of this problem the last time he was discharged. And anyway, right now [laundry list of tests] have all been completed, and show that the problem is completely under control. The best thing is for him to get back home and on the road to recovery, and you just let us know immediately if anything concerning comes up.”
Spouse: “They should have listened to me the last time. . .”

Which is such a horrible note to close on if, as there’s a decent chance given his underlying disease, the poor fellow gets sick again and has to come back. But right now he’s fine, and he wants to go home, and I want him to go home, so please, try and give some credence to the long list of negative test results. Some people do seem to feel better after you explain it all in detail; but this lady had our negligence firmly in her head, and she wasn’t listening to reason. Ah well. I’m sure we can resume the discussion at the next admission.

I’m beginning to think there’s either something wrong with me doing what I’m doing, or with how I’m doing it.

I figured out today that the way the guys were talking about the attendings wasn’t bad at all. I know this, because today I was present when a fair number of the residents started to give their uninhibited opinion of a few other residents, and it was not pretty.

I didn’t know what to do, except try unsuccessfully not to laugh. Granted, the people they were discussing have some peculiar mannerisms, and some of them are not the brightest pennies. But only one of them would I call downright irresponsible. The others are trying to do well, and just don’t quite match the other residents’ ideas of normalcy or success. So the senior residents are mocking away, and it really was hilarious, between their imitations and made-up lines, and actual quotes from the residents in question. (For instance, on the subject of how to avoid adding consults to one’s list of patients to see in the morning, they stated that one resident quite surpassed their expectations, by flatly lying to the medicine service (or perhaps she was just confused on the subject) about whether her group would consider seeing a certain patient. The internists took her at her word, and consulted another service. The surgery residents considered this a desirable outcome, but by astonishingly unethical means.)

So that was a bad thing to do, and fair to laugh at, I suppose. (Although really somebody ought to tell this resident how incredibly awful her performance is, and how horrified the rest of the residents and the attendings are by her either complete incompetence, or thorough dishonesty - no one is quite sure which it is. We’re hoping incompetence, which would make it funny, rather than dishonesty, which would make it reprehensible.)

But what about the other guys, who just have some unfortunate idiosyncrasies? I feel like I ought to say something along the lines of, “that’s not polite,” or “that’s not kind,” or “how would you like it if people talked that way about you?” (which indeed they sometimes do). But that would sound so completely schoolmarmish, and would only result in them not talking around me, and no doubt adding to the stories they tell about me. (I’m sure I’m shy and hesitant and socially inadequate enough to have plenty of jokes circulating about me.) Then that reminds me of Mark in That Hideous Strength, and what crimes he was led into by his desire to be part of a inner group; which is what the surgery residents have always been to me. Now nearly a proper resident, I’m getting closer and closer to being part of the inside group, and their pull on me is getting stronger.

Anyway. And then there’s the whole matter of women’s proper role in society (which the affair of the fundamentalist Mormon ranch brought up), on which I can’t say a single thing. I want to praise women who stay at home and take care of children, and I want to uphold a husband’s authority over his wife. But I can’t say a thing about what I really believe, and just have to listen to the conversation in silence, because if I open my mouth, I will instantly lose any chance of having equal dibs with the guys at the big cases, of being respected in the trauma bay or at ICU crises, of being listened to when I become more senior. I’ve never had to keep this quiet about my beliefs before. It makes me think I’m doing something wrong.

I’ve studied so much the last couple days I feel like I’m bursting. Apparently I’ve discovered the secret to studying at the hospital: don’t bring any other books in, and have nothing of the slightest interest occurring in the world, so that reading news sites and commentary is more boring than reading a textbook. Actually the surgery books are fascinating, especially since I asked the chief for some recommendations. I’ve now discovered a book I clearly should have been reading since the beginning of the year, Chassin’s Operative Strategy for General Surgery, which explains how to think about operations, and all kinds of details of practice that I’ve learned exist, by stumbling against them, but never really heard why they are that way. And then of course the usual assortment of gigantic textbooks, in one or two or three volumes, which are certainly not boring, but can be very discouraging: flip through any one at random, and there are nearly 2,000 pages of dense information that I ought to know and would like to know - and it takes forever to read any one chapter.

At least I finally figured out that nowadays one operates on acute cholecystitis within the first few days. (Yes, I told you I was a bad surgery intern; it took me nine months to figure that out. My only excuse is that this is the first month that I’ve spent much time with plain old general surgery - except August, and I wasn’t conscious then.) Somehow I had gotten the impression in medical school that one operated urgently on small bowel obstructions, and tried to wait six weeks before operating on cholecystitis (infection of the gallbladder, usually due to stones blocking the cystic duct) and biliary pancreatitis (inflammation of the pancreas due to gallstones getting stuck in the common bile duct), so I kept being puzzled when the surgeons here operated a lot sooner. My current program isn’t the most innovative, but apparently it’s a generation ahead of my medical school program, because all the current literature (it wasn’t even hard to find) says that it’s best to operate immediately, before too much scar tissue and other complications develop. (And for biliary pancreatitis within a few days, as soon as the pancreatitis seems to resolve, because it will likely recur if you wait much longer.) (And you should wait a few days to see if a small bowel obstruction will resolve on its own - more than 80% do - and only rush to surgery if the patient is toxic on presentation. That I did figure out a while ago.) So very slowly, I’m learning a couple of key concepts. (This kind of information you won’t find in the textbooks, which are a couple of years behind recent research, and also, for all of the data that they cram into those books, they still don’t seem to have much application to daily life on a surgery service. Obviously I need to read some more, till I get to the relevant part.