I couldn't make it to the gym yesterday. It always seems that the days we need those endorphins the most are the days we can't get there.
Would killing my intern be considered a cardiovascular workout? I guess it would depend on the method. Shooting? No. Stabbing? Maybe. Multiple stabbings? Possibly. Strangle with bare hands followed by kicking/jumping? Definitely!
Oh, and I'm not just being an evil chief here. He completely deserves it. He's like a negative resident. It would be easier if he weren't even here and we had to split his work up among the rest of the team. He coutns as negative because he has to be checked up on, which takes longer than actually just doing it yourself. :-P
Showing posts with label daily life. Show all posts
Showing posts with label daily life. Show all posts
Thursday, January 17, 2008
Thursday, January 3, 2008
what do you say? part I
Medical school can teach you a lot of things. Most of what they teach, they do very well: pharmacology, anatomy, physiology, pathology... One thing they don't spend much time on is how to deliver bad news. If they do have a one hour lecture devoted to it, consider yourself lucky. But something like that can't be taught in one hour. For some, even a lifetime isn't enough.
Learning how to deliver bad news seems to be part of the job description of a physician. We can't cure everything that crosses our paths. People don't get better, become debilitated, die. We should be able to do this very well.
For us, the new year has brought us to new rotations. I'm still on vascular surgery, but I'm at a different hospital. I've inherited some very sick patients who have run out of options.
One woman is in her 80's. She is on dialysis, which requries the ability to remove blood at a high rate, run it through a filtration machine, and return it to the body at the same rate. This is usually performed through what is called "access." Access can take the form of a fistula or graft in the arm, which is where we surgically make a connection between a large artery and a large vein in the arm. Or it can be via a large bore catheter with two ports sitting in one of the large veins in the neck.
Eventually, fistulas will become clotted and stop working. We can try to save the one they have through various means, but sometimes they need a new one. So you march up the arm towards the axilla making more connections between artery and vein in an attempt to keep them on dialysis.
Once all those spots on both arms are used up, you can try to do something in the groin. But these can become infected and don't usually last that long. Then all you're left with is the catheter version of access, which carries with it risk of infection or clotting of the vein in which it sits.
What happens when you run out of places for the catheter and something else hasn't killed you first? You die of renal failure. It's not a horrible death, really. The toxins in your blood make you sleepy so you just get to the point that you go to sleep and don't wake up.
Back to my patient. She's in her 80s and she's used up all the spots on her arms. All of her large veins are clotted. She is currently receiving dialysis through a catheter that is placed through a lumbar vein that goes directly into the inferior vena cava. That's the last spot. And even that is more than most people get.
Let's complicate things a bit more. We've been keeping her anticoagulated (blood thinned) on coumadin to help prolong the day when she will clot off that catheter. But for some reason (that happend before I got on the service) the blood was thinned too much (INR = 12) and she had an upper GI bleed. We the surgeons and the medicine doctors have weighed the risks; continuing anticoagulation to prolong the inevitable is not worth risking another potentially fatal GI bleed. Which would mean that we need to talk about the time when the catheter clots and we need to set up hospice care for her.
Add this to some very dysfunctional family dynamics involving debates over religion and a language barrier, and I'm a loss. Today we had a family meeting with a skilled palliative care specialist who is helping us from a hospitalist standpoint. He was able to cut through the communication issues with the family and get them to agree that the patient will indeed make her own decision about stopping anticoagulation or not. They will only become involved when she is unable to make decisions for herself. That conclusion alone is a huge help; before this meeting the daughter told me that she was "not authorizing" me talking to her mother via an interpreter about these issues.
Now that I have permission, I just have to do it. I've had these discussions before. I'm sure I could do them better. I hope I can show compassion but give her the facts she needs all at the same time.
Part 2 will include another difficult conversation I had today...
Learning how to deliver bad news seems to be part of the job description of a physician. We can't cure everything that crosses our paths. People don't get better, become debilitated, die. We should be able to do this very well.
For us, the new year has brought us to new rotations. I'm still on vascular surgery, but I'm at a different hospital. I've inherited some very sick patients who have run out of options.
One woman is in her 80's. She is on dialysis, which requries the ability to remove blood at a high rate, run it through a filtration machine, and return it to the body at the same rate. This is usually performed through what is called "access." Access can take the form of a fistula or graft in the arm, which is where we surgically make a connection between a large artery and a large vein in the arm. Or it can be via a large bore catheter with two ports sitting in one of the large veins in the neck.
Eventually, fistulas will become clotted and stop working. We can try to save the one they have through various means, but sometimes they need a new one. So you march up the arm towards the axilla making more connections between artery and vein in an attempt to keep them on dialysis.
Once all those spots on both arms are used up, you can try to do something in the groin. But these can become infected and don't usually last that long. Then all you're left with is the catheter version of access, which carries with it risk of infection or clotting of the vein in which it sits.
What happens when you run out of places for the catheter and something else hasn't killed you first? You die of renal failure. It's not a horrible death, really. The toxins in your blood make you sleepy so you just get to the point that you go to sleep and don't wake up.
Back to my patient. She's in her 80s and she's used up all the spots on her arms. All of her large veins are clotted. She is currently receiving dialysis through a catheter that is placed through a lumbar vein that goes directly into the inferior vena cava. That's the last spot. And even that is more than most people get.
Let's complicate things a bit more. We've been keeping her anticoagulated (blood thinned) on coumadin to help prolong the day when she will clot off that catheter. But for some reason (that happend before I got on the service) the blood was thinned too much (INR = 12) and she had an upper GI bleed. We the surgeons and the medicine doctors have weighed the risks; continuing anticoagulation to prolong the inevitable is not worth risking another potentially fatal GI bleed. Which would mean that we need to talk about the time when the catheter clots and we need to set up hospice care for her.
Add this to some very dysfunctional family dynamics involving debates over religion and a language barrier, and I'm a loss. Today we had a family meeting with a skilled palliative care specialist who is helping us from a hospitalist standpoint. He was able to cut through the communication issues with the family and get them to agree that the patient will indeed make her own decision about stopping anticoagulation or not. They will only become involved when she is unable to make decisions for herself. That conclusion alone is a huge help; before this meeting the daughter told me that she was "not authorizing" me talking to her mother via an interpreter about these issues.
Now that I have permission, I just have to do it. I've had these discussions before. I'm sure I could do them better. I hope I can show compassion but give her the facts she needs all at the same time.
Part 2 will include another difficult conversation I had today...
Monday, December 31, 2007
'07 ---> '08
This coming year is going to be one of great change for me. I'll be graduating in just six and a half short months. Finally, after over a decade, I'll be a "grown-up." Qualified to do what I have been called to do. I'll have to go out there and find a job. Fight with insurance companies to get paid for what I do just like every other surgeon in America. I'll have to sit for the Qualifying Exam to be a board certified surgeon. Somehow I'll have to find the confidence that has been eluding me that I am competent.
We in the medical field are used to change. We deal with it daily. We expect it. Why else would we admit someone for "serial abdominal exams"? We are ever prepared for the moment when the generalized abdominal pain turns into peritonitis and we're heading down to the operating room.
People generally don't like change. Change is scary. It requires you to alter your way of thinking. Even when people stay awake past midnight, they don't register the fact that the calendar day is different from the one in which they woke up. It's just easier to pretend it's the same day and things change while we sleep. But many of us find ourselves working past that magical moment that makes one day past and the next one present. We can't pretend; it is imperative that we change our mindset and put in the medical record that it is a new day. Sometimes, when I am exceptionally tired, I'll subconsciously fight that. Even well into the next morning, I'll put the wrong date on notes and have to scratch it out. The new day came; sometimes with me, sometimes without me. But tonight is different. Nearly all the world will be cognizant of that moment. And with that will be celebrations of change... of a new day... of a new year.
So here's to the new year. Learn what you can from last year and then let it go. Get ready for 2008 -- for the planned and the unplanned.
Cheers
We in the medical field are used to change. We deal with it daily. We expect it. Why else would we admit someone for "serial abdominal exams"? We are ever prepared for the moment when the generalized abdominal pain turns into peritonitis and we're heading down to the operating room.
People generally don't like change. Change is scary. It requires you to alter your way of thinking. Even when people stay awake past midnight, they don't register the fact that the calendar day is different from the one in which they woke up. It's just easier to pretend it's the same day and things change while we sleep. But many of us find ourselves working past that magical moment that makes one day past and the next one present. We can't pretend; it is imperative that we change our mindset and put in the medical record that it is a new day. Sometimes, when I am exceptionally tired, I'll subconsciously fight that. Even well into the next morning, I'll put the wrong date on notes and have to scratch it out. The new day came; sometimes with me, sometimes without me. But tonight is different. Nearly all the world will be cognizant of that moment. And with that will be celebrations of change... of a new day... of a new year.
So here's to the new year. Learn what you can from last year and then let it go. Get ready for 2008 -- for the planned and the unplanned.
Cheers
Tuesday, December 18, 2007
am i glowing?
I'm still on vascular. Been sprayed a few more times. If it's not blood, it's contrast that we use for the endovascular stuff. Which, by the way, there is a lot of. Five or ten years ago, a chief resident's experience on vascular surgery meant a lot of complicated "re-plumbing" jobs: extra-anatomic bypasses like axillary-axillary-femoral-femoral bypasses, in situ bypasses like femoral-popliteal bypasses or femoral-anterior tibial bypasses, elective open AAA repairs, and access for hemodialysis.
The access hasn't changed much; there are still just as many people getting into renal failure from hypertension or diabetes than there ever were. Maybe even more. But most of those big bypasses have fallen out of favor now that we have endovascular techniques. When I explain it to people, I tell them that we are trying to fix their pipes from the inside instead of laying new pipes. Roto-rootering and stenting whenever possible. No big incisions for these guys to heal, which often never healed anyway and ultimately ended up in amputation.
That means we have to use contrast and x-ray to see our work and to tell us which vessels to fix. Which means that I'm getting exposed to tons of radiation. I didn't realize just how much until last week when we tried to fix a leaking AAA with endovascular techniques. Yes, I know it's an emergency and an argument can be made that we should have just done an open rapair to begin with, but this guy was hemodynamically stable when we started and my attending thought this would be the best thing for him... provided it worked. (It didn't, by the way. He started to crash, we opened, repaired it, and he died in recovery.)
The drive in total for that one case was over 90 minutes of x-ray exposure. That's more than the recommended exposure in one month, someone told me. Not to mention the fact that the hospital does not provide leaded glasses to protect our lenses from developing cataracts, which is a known long-term consequence of x-ray exposure. How is that even allowed?
I have another combined open/endovascular case tomorrow. With an attending who says that for endovascular work, "Time should stand still." Easy for him to say, he's old and he's already had his kids. Not to mention the fact that he's an older attending and is himself still trying to master the various endovascular techniques that are available and does most of the case himself. Not to toot my own horn (and if you knew this attending, you'd know I'm *not*), but *I'm* much faster at endovascular procedures than he is.
The access hasn't changed much; there are still just as many people getting into renal failure from hypertension or diabetes than there ever were. Maybe even more. But most of those big bypasses have fallen out of favor now that we have endovascular techniques. When I explain it to people, I tell them that we are trying to fix their pipes from the inside instead of laying new pipes. Roto-rootering and stenting whenever possible. No big incisions for these guys to heal, which often never healed anyway and ultimately ended up in amputation.
That means we have to use contrast and x-ray to see our work and to tell us which vessels to fix. Which means that I'm getting exposed to tons of radiation. I didn't realize just how much until last week when we tried to fix a leaking AAA with endovascular techniques. Yes, I know it's an emergency and an argument can be made that we should have just done an open rapair to begin with, but this guy was hemodynamically stable when we started and my attending thought this would be the best thing for him... provided it worked. (It didn't, by the way. He started to crash, we opened, repaired it, and he died in recovery.)
The drive in total for that one case was over 90 minutes of x-ray exposure. That's more than the recommended exposure in one month, someone told me. Not to mention the fact that the hospital does not provide leaded glasses to protect our lenses from developing cataracts, which is a known long-term consequence of x-ray exposure. How is that even allowed?
I have another combined open/endovascular case tomorrow. With an attending who says that for endovascular work, "Time should stand still." Easy for him to say, he's old and he's already had his kids. Not to mention the fact that he's an older attending and is himself still trying to master the various endovascular techniques that are available and does most of the case himself. Not to toot my own horn (and if you knew this attending, you'd know I'm *not*), but *I'm* much faster at endovascular procedures than he is.
Wednesday, November 28, 2007
recurring dream
I almost never dream. Well, that's not entirely accurate. I'm sure I do, I'm just too asleep to remember any of them. Unless they're bad. And I don't have a lot of nightmares either.
But recently, I've had several nightmares about work. Which doesn't make any sense, because I'm not stressed at all. I mean, last week, my service was down to zero patients. ZERO. So why I'd be having nightmares now about work is baffling.
The first one I remember vividly -- also uncharacteristic. I was in the OR at our main hospital and we were doing some routine general surgery case laparoscopically. Except they wanted me to use the da Vinci robot, which I have only seen being used from across the room. I sat down at the unit and tried to manipulate the instruments that were in the patinet's insufflated abdomen, but it wouldn't work. They wouldn't move. The attendings in the room were lauging at me and then they got frustrated that I couldn't do the operation and took over, all the while making comments about how incompetent I was. Then I woke up.
I then had the same dream twice. I don't remember what happened, but I know it was something similar that happened because I felt the same way. I hope this all gets worked out soon, whatever it is. This fluffy psychiatry stuff is all very frustrating...
But recently, I've had several nightmares about work. Which doesn't make any sense, because I'm not stressed at all. I mean, last week, my service was down to zero patients. ZERO. So why I'd be having nightmares now about work is baffling.
The first one I remember vividly -- also uncharacteristic. I was in the OR at our main hospital and we were doing some routine general surgery case laparoscopically. Except they wanted me to use the da Vinci robot, which I have only seen being used from across the room. I sat down at the unit and tried to manipulate the instruments that were in the patinet's insufflated abdomen, but it wouldn't work. They wouldn't move. The attendings in the room were lauging at me and then they got frustrated that I couldn't do the operation and took over, all the while making comments about how incompetent I was. Then I woke up.
I then had the same dream twice. I don't remember what happened, but I know it was something similar that happened because I felt the same way. I hope this all gets worked out soon, whatever it is. This fluffy psychiatry stuff is all very frustrating...
Thursday, November 22, 2007
grateful
...for what I learn from my patients, my attendings, and my students.
...for being present in people's lives when they are the most vulerable and being in a position to offer comfort.
...for whatever abilities I have to do my job.
...to belong to a profession that prides itself in the care of others.
...to be able to experience life-long learning in an ever changing world.
...for the health of my friends and family.
Happy Thanksgiving
...for being present in people's lives when they are the most vulerable and being in a position to offer comfort.
...for whatever abilities I have to do my job.
...to belong to a profession that prides itself in the care of others.
...to be able to experience life-long learning in an ever changing world.
...for the health of my friends and family.
Happy Thanksgiving
Thursday, November 8, 2007
day after thanksgiving
I just found out that we have clinic the day after Thanksgiving. Whaaa??? Isn't that a holiday or something? Not that I expected to get it entirely off scott free, becuase that doesn't happen in residency. But I thought that I'd have to go in, round on my peeps, and head to my nearest mall to get great holiday deals.
But alas, I wiil be in clinic until at least noon, after which my attending will most assuredly want to round, since the OR will be closed except for emergencies. So I'm looking at the mid afternoon before I'm free. On what should be a holiday.
Excuse my particularly whiney mood at the moment. I'll be back to being a kick-ass surgical resident in a bit.
But alas, I wiil be in clinic until at least noon, after which my attending will most assuredly want to round, since the OR will be closed except for emergencies. So I'm looking at the mid afternoon before I'm free. On what should be a holiday.
Excuse my particularly whiney mood at the moment. I'll be back to being a kick-ass surgical resident in a bit.
Monday, November 5, 2007
girls in surgery
There aren't many of us, at least in my program. I'm not sure how other programs are. And it's not because there is any active prejudice against girls per se. After discussing the issue with scores of medical students over the last four years, it really boils down to what people perceive about surgery; both in training and when you're all grown up.
I think those perceptions may have been well earned in earlier years. But now, the way the business of medicine has changed, I think a busy lifestyle is true for surgery as well as pediatrics or internal medicine, which are the other "acceptable" fields for females in medicine. For example, I know an internist who is a partner in a medical practice. She took some maternity leave and then on her months off, had to actually *pay* the business for overhead and such. When she finally did go back to work, she was extraordinarily busy, but she realized that her children needed her; she decided to take some a sabbatical to figure out how she was going to balance her home and work lives.
In my program there are a total of six female residents. We would have had more, but several left for personal reasons or from social pressures in their own lives. Not from any pressure from within the residency. As the most senior female, I have decided to institute a monthly Girls in Surgery dinner. A chance for us to relax and talk about work... or not. First dinner is tonight!
I think those perceptions may have been well earned in earlier years. But now, the way the business of medicine has changed, I think a busy lifestyle is true for surgery as well as pediatrics or internal medicine, which are the other "acceptable" fields for females in medicine. For example, I know an internist who is a partner in a medical practice. She took some maternity leave and then on her months off, had to actually *pay* the business for overhead and such. When she finally did go back to work, she was extraordinarily busy, but she realized that her children needed her; she decided to take some a sabbatical to figure out how she was going to balance her home and work lives.
In my program there are a total of six female residents. We would have had more, but several left for personal reasons or from social pressures in their own lives. Not from any pressure from within the residency. As the most senior female, I have decided to institute a monthly Girls in Surgery dinner. A chance for us to relax and talk about work... or not. First dinner is tonight!
Friday, November 2, 2007
the team
I cannot underestimate the importance of your team in the workplace we call the hospital. It can make or break you. Or your patients. I'm positive that is true for other areas of business, so forgive me for stating the obvious.
But I had to anyway. To pay homage to my new team, which was created on November 1st when we changed rotations. Everyone pulls their own weight. We all do what we are supposed to do. Even working in the clinic is not painful. The front and back office staff are fun, the love the patients every but as much as we do, and they are competent. (For any non-surgeons out there, clinic is one of the worst places to put a surgeon. Sure, it's where we meet patients we can eventually operate on, but really all we want to be doing is actively fixing something.)
So here's to my new team. Cheers.
But I had to anyway. To pay homage to my new team, which was created on November 1st when we changed rotations. Everyone pulls their own weight. We all do what we are supposed to do. Even working in the clinic is not painful. The front and back office staff are fun, the love the patients every but as much as we do, and they are competent. (For any non-surgeons out there, clinic is one of the worst places to put a surgeon. Sure, it's where we meet patients we can eventually operate on, but really all we want to be doing is actively fixing something.)
So here's to my new team. Cheers.
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