no Christmas cheer

The day improved dramatically once we stopped rounding, and I could actually go take care of the patients, instead of talking about them.

Then we got one of the requisite holiday tragedies in the ER – child abuse, burns. A beautiful child, completely silent, shaking uncontrollably, not making a sound no matter what we did. After getting ivs and starting fluids, the women in the room thought that washing the child would be good, but as soon as we poured some saline out, the child started acting like a wild animal, grabbing for the water to drink. We could only conclude that it hadn’t been fed for days. 

After sorting out some other medical issues, we had time to clean up the burns properly (initial treatment having been to cover them with saline-soaked gauze, but once it appeared that the child would be staying for a while before transferring to a burn center, we couldn’t leave it like that). Surgeons are like the plumbers of the hospital: anything hands-on is automatically ours. This was one job I didn’t mind (compared to some frustrating Gtube consults) (plus I was standing there literally pushing fluids anyway). We warmed a lot more saline and washed everything down, and then put silvadene all over. Washing burns is hard because it looks like you must be hurting the patient so much, but once you get things clean, putting the silvadene on actually makes it feel better. And of course it made the staff feel better, to have things clean and wrapped up neatly. The aides brought juice and cookies, but by the time we had it cleaned up and covered in warm blankets, the child fell asleep with gingerbread in its hand.

The only problem is now I can’t get the smell of dirty burns off my hands. I slathered silvadene all over the child, and I’ve washed my hands a dozen times, and they still smell like burns that have been neglected for days. . .

The nurses and I discussed quitting work for the evening – and the next several days – and taking the child home with us to cuddle and nurse. The child didn’t even know it was Christmas, which struck the nurses as nearly as criminal as anything else that had happened. Everyone who saw it gave it presents – a very inadequate attempt to apologize for the injustice of life. It’s just as well for the parents that they were not in evidence, because I think they might have gotten hurt if they’d come around the ER staff.

(And no, the child is not an “it,” we’re having a try at anonymity.)

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Merry Christmas

Merry Christmas, everyone.

Right now I’m feeling very grinchy because 1) I hate modern Christmas music, and it’s all over the hospital today  2) rounding for 3 hrs on 15 patients – not in the ICU – has got to count as cruel and unusual punishment, and I’m looking for a sample letter from Guantanamo to help me draft a letter to the UN Human Rights Commission to get some redress of grievances.

And to make it worse, the attending keeps saying, “We’ll just hurry up here so we can have some free time on Christmas,” and then makes you repeat yourself three times, and then looks it up again anyway, and then asks illogical questions, and spends ten minutes trying to make a decision, and decides to wait till tomorrow and see how it goes. . . I’d rather just start at the beginning and say, We will do a thorough housecleaning, why not on Christmas morning, and this will take all day.

Can anyone get me a lawyer? I need a hearing with the Supreme Court.

And finally, no one in the hospital cooks nearly as good as my mother, and looking at all of the examples of the American idea of Christmas food is also driving me crazy. If only I weren’t here, I and my family could do so much better than this – fake chocolate on crackers, storebought cooked meat, cookies without any flavor at all.

All I need is a long white beard and I’d be Scrooge’s twin.

[this is so unchristmas-y I wasn’t going to post it at all, but it’s been quiet on here, and I feel better for writing it down, so here we go; maybe when I get out tomorrow I’ll go play my CDs of antique Christmas music, and post some of it on here]

 

Arte y Pico

This is an extremely belated acknowledgment of a lovely award that this blog was nominated for by two people, an incredible honor. Thanks, Jeff and Jill, and sorry for waiting so long to write this.

Hmm, this would work better if I knew how to put pictures in here. Anyway, this is the Arte y Pico award (click to see the picture), and these are the rule:

1) You have to pick 5 blogs that you consider deserve this award for creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
2) Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
3) Each award-winning blog has to show the award and put the name and link to the blog that has given her or him the ward itself.
4) Each winner and each giver of the prize have to show the link of the Arte y Pico blog , so everyone will know the origin of this award.
5) To show these rules.

I guess we’ll stick to medical blogs, so here are my nominations (from those who haven’t been named yet):

1. Ten Out of Ten, for his witty observations on life in the ER.

2. Anesthesioboist, a musician who is also an anesthesiologist and a mother.

3. Suture For A Living, a blog that combines beautiful quilts, medical stories, and some of the most educational posts in the medical blogosphere.

4. Happy Hospitalist, for his honest and all-too-depressing explanations of real-world economics and their impact on medicine.

5. Agraphia, an eloquent and funny blog by a medical student (good luck with step 2, Zac!).

Sorry for the lack of illustrations, I’ve been putting this post off for too long, and if I wait to figure out the technology, it will never happen. Go read those five blogs. They all have beautiful graphics in addition to good writing.

 

hilarious

I have to link again to Frank Drackman’s (highly R-rated) list of differences between surgeons and internists. Among them, “internists spend ten minutes securing a central line and it still falls out” – drove me crazy when I was sharing my patients with a MICU team. I didn’t want to say I could put a line in better than the medicine intern, but I sure knew I could sew it in tighter. (And anesthesiologists, Dr. Drackman, just don’t sew the arterial lines in at all, because by the time it falls out, the patient will be out of the OR; and because the surgeon is hounding them to start the case.) And “surgeon knows it’s an artery because it’s squirting across the room at 150mmHg;” yeah, I’ve seen my share of those. As long as the patient’s not hypotensive, there’s not much mistaking an arterial puncture or laceration.

 

pay the piper

Somewhat related to yesterday’s post:

Today was splendid. I spent the entire day in the OR, running from one thing to another, so much so that at the end of the day I realized with horror that I’d hardly paid any attention at all to my floor patients. Fortunately, they were all with good nurses, so I was able to reassure myself while scrubbed in that I would have been paged if anything had been wrong; and indeed they were all cruising along smoothly when I went to check after the cases were finished.

Anyway, I had a tremendous time, being with one of the attendings who doesn’t believe in giving constant instructions. He just kind of stands there (after very carefully marking the place to start; my blog’s title is no joke), and lets you call for the instruments from the tech, make the incision, and proceed as you see fit. He says something if you’re about to do something absolutely disastrous; otherwise, he just hums a little bit and smiles to himself. Since he’s slightly deaf, no little hints like murmuring, I s’pose this is where we go next, will get you any help. You have to say loudly, I’m not sure what to do next, if you want to get any directions; which is of course a surrender and an embarassment to say, so you keep trying. But so amazing to realize that I actually do know a great many useful things to do.

At the end of the day, rounding with the chief, he could see that I was enjoying myself vastly. He smiled at my account of the day’s proceedings and said, “You know, Alice, you’re going to have to pay for your fun eventually.”

What he meant was that all these cases were on the schedule because he and the attending had been called several times a night for the last five nights, the team being on call. All I had to do was admit a few patients in the afternoon, and see a longer list in the morning, and then I got to do cases. He was the one who’s been awakened by calls at home several times a night for the last two years, and he and the attending were the ones who came in for emergency cases over the weekend. They’re tired.

And I was thinking. The chiefs at this program operate all day every day, it seems like. But they pay for it. They look pretty tired – noticeably more so now, at the end of the year, than at the beginning, when the cycle was just starting. They are never not able to do anything that’s called for; but they’re exhausted a lot, and they look like it. Most of them have grey hair. None of them are much past thirty, but they look older, especially after a string of days and nights with their attendings on call.

He’s right. I thought I was paying in advance, this year, doing all the pre-op and post-op work and not getting to operate. But next year, covering all the surgical patients at night, I’ll start paying; and after that, taking real call continuously – that’s when the bills come due. I’m worried about next year; but I’m even more scared of having a chief’s responsibilities. That’s only a little more than two years away. I need to stop doing math.

 

SurgExperiences, 10th Edition

Welcome to the 10th edition of SurgExperiences, a blog carnival dedicated to all things surgical. (And apologies for the late appearance; I realized at work tonight (where blogs are blocked from computers) that this was the important event I’d forgotten about when my days and nights got mixed up.)

The posts from our contributors this edition are so fascinating that I am sure you will enjoy them despite the lack of any fancy graphics here.

First, my favorite: Bongi’s tales of the black mamba. Read on to discover what dangerous anatomical structure he’s referring to. Also from Bongi (guest posting on All Scrubbed Up) a hilarious post on the realities of life in the OR.

Surgical education and error
Orac explores a recently published study of surgical errors showing more errors are made by experienced surgeons doing common operations (not necessarily junior surgeons just learning the operations).

A journalist comments on the difficulty of accurately measuring the number of wrong-site surgeries.

Buckeye Surgeon presents a case of wasted resources on the road to definitive surgical treatment. Orac expands on this with a scathing indictment of surgeons’ refusal to be involved in anything which doesn’t directly lead to cutting on a patient as a source of inefficiency in American healthcare. As an old-fashioned advocate of the surgeon being responsible for pre- and post-operative care, I echo the commenter who remarked that internists are ill-fitted to be responsible for the medical management of surgical
diseases, since they’re not trained to recognize when the patient has failed medical management. I recently saw a similar scenario play out, where a patient was admitted and had a million dollar workup for possible cardiac origin of epigastric pain. He returned to the ER the next day with excruciating epigastric pain, which yours truly recognized pretty quickly; a simple set of liver enzymes and an ultrasound revealed the gallstones which were the true culprits. So much for medical management.

Buckeye Surgeon also meditates on the complexities of educating residents.

From beyond the blood-brain barrier
A reminder from our anesthesia colleagues that good anesthesia counts.

Terry at Counting Sheep presents a lament for abandoned elderly people being “treated” by surgery that can do nothing to truly help them.

A tale of chaos in the OR that trumps any I’ve heard yet – glad I’m not working at that hospital.

From the front lines
A picture is worth a thousand words: military surgery in Iraq.

From the inimitable Dr. Schwab, an essay in fiction which leaves me shaken. Dr. Schwab explores possibilities I’d rather leave in silence.
Also, a collection of his best real-life stories.

Plastic surgery weighs in
Educational summaries by Suture for a Living on extravasation injury from chemotherapy agents, and on the potential for skin necrosis from the use of methylene blue dye in identifying sentinel lymph nodes during breast cancer surgery.

From another plastic surgeon: a discussion of how much bariatric surgery vs. plastic surgery can contribute to decreasing the morbidity associated with obesity.

Medical education
Jeff at Monash Medical Student makes plans to not faint during long cases. For his encouragement, I will admit to coming close to fainting during burn cases. (Ok, so you try turning the temperature up to 85 F, putting on a long paper gown, covering your face with a nonpermeable paper-and-plastic concoction, holding a heavy extremity motionless for twenty minutes, and see if you don’t get orthostatic.)

On a similar note, advice for medical students on what to do when scrubbed in.

Thank you for visiting. I hope you’ve enjoyed this collection of surgical blogs. The next edition of SurgExperiences will be hosted by Buckeye Surgeon on December 23. You can view past editions of SurgExperiences here, and if you are interested in hosting a future edition, you can find out more at that site. (I highly recommend hosting this carnival, if only because it obliges you to read all of the posts. I discovered several fun new blogs this way.)

 

why tv is dangerous

This is going to come close to rivalling my old story about Dr. House in real life:

Doctor: This procedure is really important to help us understand what’s making you sick. There are very few risks, and it’s relatively simple to do.
Patient: But whenever they do this on House, it always looks like it really hurts. I don’t want that.
Doctor (grinding teeth quietly): Don’t believe what you see on TV.

a comfortable conversation about art and Christmas preparations later:

Doctor: There, all done.
Patient: Already?
Doctor: So was it as bad as on House?
Patient: Nothing like that at all; I hardly felt a thing- they have no idea what they’re talking about!

See? Watching House/ER/Grey’s Anatomy/Scrubs can be hazardous to your health (or, if you’re a health professional, you already knew that you put yourself at risk of apoplexy by watching).

 

one way to find out

One of my patients is sick, and there are two schools of thought about him. When I get back tonight, we’ll see if he’s in the ICU or not, and then I’ll know whether my hunch was right. For his sake I hope I’m wrong.

Or maybe he’ll just be waiting for Brad and me to take him to the ICU tonight. . .

 

Stockholm

For how much I complained about this rotation for the last month, I’m surprised by how sad I feel about leaving. Almost every single night I was angry at the residents for making me stay so late. I guess it paid off somehow, because this last week they’ve trusted me with a lot of things, to wit, their call pager. Which is their way of getting to do surgery and not worry about minor details like the urine output, intracranial pressure, blood pressure, or temperature of the ICU patients. (They do care, really, and much more efficiently than I do; but in the OR it’s a distraction.) The junior residents especially, I think, have enjoyed dumping all their calls from the ER on me. I know that most of their interns haven’t done this much work.

But it goes two ways. Even though they were dumping on me, they trusted me; and I like that. I was starting to feel like part of the team this last week (albeit the team’s division of labor consisted of: Alice, write the notes, write the orders, see the consults, and do the admissions, while we are in the OR and clinic).

This morning they discovered one of my management plans from yesterday afternoon, which at the time had seemed so simple that I hadn’t thought to check with one of them. So of course today on rounds everyone was exclaiming about what a bad idea it had been, how completely and obviously wrong, and how detrimental to the patient’s physiology. I spent about an hour feeling guilty for 1) hurting the patient, 2) not checking with them (which was my one real mistake), and 3) still not realizing why my method had been wrong. Then the repeat labs came back, and the patient’s vital signs continued to do their thing, and it became clear that I’d had the correct diagnosis and a fairly correct treatment. I didn’t feel too good about it, though, because if I’d been thinking clearly yesterday there were some even more correct things I could have done. Anway, the patient wasn’t hurt, thank God. I hate this medicine stuff: always more than one right answer. Electrolytes especially are my downfall; and that seems to be the majority of what happens in the ICU.

I also feel bad about leaving because we have some interesting patients: the above-mentioned, who turns out to have a relatively rare disorder, which I wish I could see play itself all the way out; a new subarachnoid hemorrhage in tenuous condition; some trauma patients whose final outcome I want to know; and the pleasantest guy who came in today with a sad story and a completely abnormal neurological exam, with findings I’d thought I’d never see in real life.

The chief even invited me to come around to their surgeries again, and I hope he meant it seriously, because if I get any spare time next month when he’s in the OR, I will. I feel almost drunk with what he lets me do in the OR; it’s addictive; I can’t stay away.

 

no doors

Somewhat better today. We had conference literally all morning; which was ok, because I’ve worked out an efficient way to sleep during lecture without amusing the residents and annoying the attendings by nodding visibly. (Back wall works wonders.) Neurosurgery has combined teaching with neurology; I remember why I didn’t want to do neurology, or ENT. (Although how one can look at a diagram of the inner ear, with all those delicate structures intertwined, and all the complex nerve signals which combine to let us walk and see, and not believe in the Creator, escapes me.)

My basic problem is I’m too helpful. I’m too happy to be semi-competent at doing things in the ICU to avoid work fast enough when the residents start dumping on me. It’s only after they’ve walked off (to do something else – these guys are the busiest people I’ve ever seen) that I remember that I’ve now got two extra lists of work, in addition to my own basic list. In spite of that, I got out before 6, which was an improvement. The main thing was that my patients all improved, got off their drips, and remained alert and oriented, so they could leave the ICU – to their delight. Our ICU is of the old-fashioned, open ward, flimsy curtain design. I hate that. It drives all the patients who aren’t intubated crazy, interrupts the family’s visiting hours, and essentially destroys any privacy. At least glass walls are solid.

We withdrew care on a patient today, and of course they dumped the DNR and comfort care orders on me. I wrote them in the corner while watching the family crying and praying with a minister. Somehow, it wasn’t so bad just examining the patient, seeing him lying there, looking at his hopeless labs and CTs. It felt like he was already effectively gone. But seeing the family mourning makes the patient much more of a real person – after all, I’ve never seen him conscious – and his loss much worse.