Boras deals with embarrassment
It was Schadenfreude Day in baseball, with a startling number of folks on the players' side and the owners' side united in toasting what appears to be the public humiliation of the most powerful agent in the game. Think about it: The best player in baseball issues a statement announcing he has circumvented his agent so he could rejoin the team he never wanted to leave.
Surfer dude stuns physicists with theory of everything
E8 encapsulates the symmetries of a geometric object that is 57-dimensional and is itself is 248-dimensional. Lisi says "I think our universe is this beautiful shape."
Barry Bonds indicted on perjury, obstruction charges
SAN FRANCISCO -- Barry Bonds was indicted Thursday for perjury and obstruction of justice, charged with lying when he told a federal grand jury that he did not knowingly use performance-enhancing drugs.
If convicted on all five counts, baseball's home run king could go to prison for up to 30 years.
i'd very much like to be believe that it's only my hospital that's like this, but medicine consults are the absolute worst. it's like bizarro world where i work; medicine doesn't try to diagnose things... they are way too focused on cutting first and thinking later. hey is that a superficial bump? let's call surgery to cut it open!
ring ring ring...
"surgery returning a page"
"hey, i'm calling in a consult. we've got a guy with an abscess that needs to be drained"
(note: this is the abbreviated version.. the actual consult involves useful details like "some guy with a medical history of hypertension, cataracts, and tonsillectomy in 1941 who presents with chest pain.... cardiac enzymes are negative x2, hemoglobin a1c is 5.9... ESR of 33...)
"is it draining?"
"yeah"
"ok so..."
"it was drained two days ago but i think it needs to be drained again. can you come do it?"
to make a long story short, what usually happens is that i ask a bunch of questions, #1 to find out what's really going on, #2 find any details for me to punt the consult to ortho, plastics, derm, etc, #3 see if i can delay the consult with a few studies. but in the end, someone has to be a doctor, so i usually just see the patient.
so i go see the guy. it's a firm growing mass. drainage had been attempted but nothing was expressed. interesting... oh he's also had unintentional weight loss and night sweats. oh and this "abscess" is rock hard. and there are two of them, located near a bunch of lymph nodes. and there's no surrounding erythema. and one of them is fixed. not painful.
it's not like i'm a great diagnostician. in fact i probably suck; there's a reason why i'm in surgery, and it's not to diagnose random congenital disorders or rule out #12 of my 15 point differential. anyway, the point is, come on man, there's a good chance there's more going on here than just "abscess, need I&D".
i know it goes both ways, and i know i've been forced to place my share of consults that make no sense, but i'll let an internist write about that in his or her own blog
working nights with sick patients is kind of like the movie "night at the museum". it's interesting that ben stiller, who looks like an ugly monkey, is the star of the movie, mostly because as surgical interns, we do our stupid monkey dance for the chiefs on our service. go carry some specimen across the street, or see a consult, come to the OR now to retract, come in during the weekend and write all the progress notes for a service you aren't even on...
anyway, back to the topic. the reason why working with sick patients is like night at the museum is because these patients all sleep throughout the day, and when every other resident and attending leaves, and you're the only one in the hospital, the patients all wake up and start acting crazy. the fun ones are the delirious old guys; i usually take some time to talk to them, only because our conversations are great.
"where are you now sir?"
"i'm in my kitchen. i'm making a pizza."
"oh really, what toppings?"
"oh it'll be delicious, it has mushrooms and pepperoni. if you'll just let loose, i can get to the oven before it burns!"
"sir you're in the hospital, there's no pizza in the oven. you need to be restrained because you're confused."
"confused? what about my pizzas? they're gonna burn!"
"is it thin crust or deep dish?"
then there are the ICU patients who are happily crapping through a rectal tube during the day with their GCS of 3. as soon as sign out happens, they start trying to pull out lines, tubes, decide to stop peeing through their urinary catheter, start to go into afib+RVR. they're like the chimp in the movie who throws away the keys and makes the night terrible.
also playing a part is the know-it-all ICU nurse who roughly correlates with the teddy roosevelt character in the movie. brash, annoying, and doesn't know when to mind his own goddamn business and let people do their job. no i don't want to replace the bicarb. no he doesn't need blood now. no i don't want to give FFP. no i don't want to add another pressor. no i don't want more fluids. this guy made my night a living hell. he had this cordless phone and kept it with him at all times, so that he can talk to me as if i was standing right next to him. the funny thing is, he took a verbal order from an attending, didn't ask him why, then called me to question it. i'm like, dude, you took the verbal, either do it or ask the attending yourself. and he's like no way, i can't do that, i gotta go up the chain of command. i'm like you asshole, why do you protect the attending so goddamn much but you feel free to waste my time with your bullshit suggestions? and if you want to ask the attending why he wants to do something, especially if he told you to do it, and you're the one who wants to not do it, why the fuck are you asking me, the intern who's not even on the service, who's just trying to keep people alive for 12 hrs? at a certain point i just wanted to ask him straight up, do you hate me or something? why are you doing this to me? but i guess from his dumbshit perspective they were all "good thoughts" even though i ended up veto-ing almost all of them.
got off track again haha
well here i am, into my 5th month of surgical training. i don’t know what kind of perverse rationalization and/or profound self delusion got me into this mess, but here i am, knee and elbow deep in soap suds enemas and the glorious, if not malodorous world of general surgery internship.
somehow, when i was a kid, i never imagined that i would be waking people up at 5 in the morning, asking them if they farted, pooped, or peed. or that i would sometimes be digging my finger into a demented senior citizen’s bumhole in a sisyphean effort to scoop out loose excrement from a massively dilated rectum.
i have about 10 cases under my belt. picking out a lipoma is more fun than i thought. it’s like when you pick a good size booger. except when you pick a booger you don’t have to write a post op note, dictate an op note, write post op orders, or see your booger back in clinic in a week.
masochistic moral superiority
i think a lot of general surgery revolves around masochistic moral superiority, in various interpretations of the phrase.
i think we tend to look down on people who we perceive to be slackers. like anesthesiologists for example. nurses. radiologists. even surgical subspecialists.
why? masochistic moral superiority. it’s like some relic from medieval times when people punished themselves to stay morally pure. like when religious people do all sorts of shit to themselves for having the weakness of mind and spirit to actually enjoy life. as if self punishment is good. i don’t know why general surgeons like punishing themselves. but it’s undeniable that we do.
i guess it’s the hope that after all the training and the beat down, we can become the type of people we wish to be. supremely knowledgeable, able to handle any acute problems, being a badass that knows exactly what to do at all times… or is it “sometimes wrong, never in doubt”?
why do i want to become that person and at what cost? whatever happened to the common sense view that enjoying life is the best way to enjoy life? somehow along the way, i’ve been taught to think that delaying gratification was the best way to have a happy life. and now that it’s no longer about delaying gratification but not having any hope of it at all, i have to stop and wonder, what the hell? what is so devoid in my life that i need to become some sort of hero, taking on society’s bullshit burdens?
they say internship sucks and it gets better. i ask, why can’t it get like… a lot better? am i bold enough to ask whether it can actually be good, rather than just being “better than shitty”? i think some people go to work excited about their day and find fulfillment and possibly joy from their work. i really see no hope of that in medicine. i like operating and i think i have as much natural ability as anyone when it comes to manual dexterity. not that it matters. what matters now is being able to write fast because everything is done by paper and all i do is write bullshit orders, bullshit H&Ps, bullshit progress notes, and bullshit discharge summaries. i haven’t looked forward to a single day of my 10 weeks so far, and some days i go in with a sense of dread that accounts for not only the drudgery of the day ahead but also the entire year, entire residency… perhaps entire career. going to work at 5:30am everyday gets old and i don’t know that i will ever get used to it. and why should life be about getting used to pain? i am smart, accomplished, and i work hard. so why should i suffer?
oh well back to work to check pulses and spend 5 hrs writing notes that no one reads.pre-2003: what’s the worst thing about q2 call? you miss half the good cases
post-2003: what’s the worst thing about q7 days off? you miss 1/7th the discharge summaries and hospital-to-hospital transfers
internship is not very pleasant. everyone talks about the steep learning curve and how i’ll learn so much this year. and surgical training is supposed to be about decisiveness, being trained to handle anything. i still feel like every situation i’m in requires me to consult the second year resident or above. like i can’t make a single move without running it by someone else first. i sort of felt like residency would be different. i still feel like a medical student in a long coat. well i did have a lot of independence on trauma and it blew up in my face often. i don’t know what’s worse, being unable to make any decisions, or making too many. i wonder when my decisions will magically become better.
that being said, it’s a cool feeling once in a while, to be called to the OR to finish up a case or see something sweet. when i get those rare pages from the OR nurse summoning me, i feel like clark kent changing into superman as i change from my shirt and tie into scrubs.
the other day i saw an open repair of a thoracic aneurysm, where the aorta was exposed above the diaphragm, with the heart beating away in the corner of the exposed field. i still haven’t decided whether seeing something like this is worth it all; i’m not the sort to be amazed by much, or deeply passionate about any particular thing. so i’m skeptical.
anyway, by way of updates, it’s been about 9 weeks and i haven’t quit yet.
my life outside of the hospital and from work is virtually non-existent. i’m ok with that, more or less, so far.
well i just did a week of my new rotation and i can’t really complain right now.
it’s quite a luxury to go to work knowing that i don’t hate every single one of my patients. a luxury i did not have on my last rotation. it is also quite a luxury to deal with people who have insurance, because that means i don’t have to spend hours out of every working day talking with the social workers and hoping for a miracle to get some place to accept an uninsured person with TPN, PICC, gigantic open wounds, aspiration precautions, and post traumatic stress disorder. yeah that was a fun.
i also very much enjoy the fact that we have 3 patients on my service, all of whom are in the SICU. this means that the ICU team manages my patients, and therefore, i never get paged about them. this makes my weekend call pretty awesome. on saturday i rounded on my patients for no more than 15 minutes, then promptly went to sleep. woke up, got lunch, and slept some more. then rounded on my patients one more time, then went home. on sunday, i rounded on my patients for maybe 10-12 minutes, had some breakfast, went to sleep again, then went home. and for all this hard work, i get the next two weekends completely off.
one thing i notice about working here is that everyone has piss poor hygeine. not surprisingly, a pretty good amount of our patients develop post operative infections, and many end up returning back to our services. i think the ID folks here need to get their crap together.
i also managed to log my first OR case this week. yes, that’s right. this badass surgeon just sutured some skin at the end of the case. if that doesn’t get the panties dropping i don’t know what will. 2 chest tubes and one skin closing in 5 weeks of surgery residency. a few years at this rate and i might do as many procedures as an m3 on psychiatry.
going from working my ass off and having a crapload of responsibility to hardly working and basically being a medical student is pretty sweet. i think i discovered like 9 months too late that i sort of enjoy not working very hard. i still hold onto some fantasy that all of this BS will pay off in some intangible but profound way maybe like 20 years from now, but intellectually i know this is completely delusional. and yet i persist. i think people just want to say that i keep at it because i know deep down that it’s worth it and what i really want to do, but i think the truth is a lot less profound. i think i’m just too scared to stop and admit that i don’t really care about meaning, about altruism, or intellectual development. i don’t think i want to admit that i just want to watch tv and eat potato chips on a sunday afternoon for the rest of my life. and admit that deep down, living a pointless and numb life is not the great tragedy that i wish it to be, because despite my feelings of moral and intellectual superiority, i’m actually ok with achieving nothing great, ok with not helping the needy, and basically ok with just being a regular schmoe doing his own meaningless thing that no one necessarily will remember when i’m dead. i guess when i say i wish i could be happy just like all the other thoughtless schmucks out there, i’m really saying that i wish i could admit that i am one of them, instead of pathologically deluding myself and taking some perverse gain in playing the role of a troubled and depressed intellectual and/or humanitarian.
my last day on this cursed rotation. for at least 11 months anyway.
all this talk about patient autonomy is BS. once you start working on the wards, it’s all about ativan and restraints. getting nervous? ativan. talking back? ativan. complaining too often about pain? ativan. want to pull out your NG tube? ativan. trying to pull the foley? ativan. it got to the point when even i was saying to people, “i don’t like how we treat patients here. we control them medically. i want to do things the old fashioned way and talk to them.” explain things so that they aren’t as nervous, instead of masking their nervousness with drugs.
i’m also finding that i resent patients who don’t do exactly what i tell them to do. i want to yell at them to stop using so much morphine because that’s preventing them from taking a dump and getting off my patient census. get out of bed, walk, and work with PT/OT because if you don’t, it’s me who gets yelled at during signout at 6pm. why is the patient still here? because he’s a typical lazy ass leech enjoying his stay at our $1000/night hotel with free food, cable, and phone service. somehow, i doubt that these guys who live in their pickup trucks have much motivation to leave their bed and free cable just to go back to sleeping in their car.
i’m finding i need to fight the tendency to become punitive with my idiotic patients. i know it’s not pleasant to have tubes in every orifice, but if it’s what we need to help you get better, stop being dumb and keep that shit in there! i have this dumbass who aspirates every time he eats anything, so i put in a dobhoff tube for tube feeding. this moron pulled the DHT probably more than 5 times during the time i was there. he’s constantly begging to eat something by mouth. hey listen dude, we already explained to you that if you eat anything through your mouth you WILL choke and die. if you keep pulling the DHT, we can’t feed you, and you will starve. it’s funny, when the choices are starve/choke/die vs keep a thin tube coming out of your nose, this jerk off chooses the former every chance he gets. i was pretty damn tempted to say screw it and let him starve for a day.
dumbass patients create exponentially more work for me. just think… if this asshole didn’t pull his tube 3 times, i wouldn’t have had to write 3 orders to put in a tube, 3 orders for a stat KUB, look at the xray 3 times to check the placement, or tell the nurses to pull back on the tube just a little bit… and get another KUB, look at more xrays, etc. all this fucking work to feed some loser. if i ruled the world, noncompliant patients like this would be kicked out of the hospital, and if they choked and died, that would be their damn fault, and it wouldn’t be my responsibility to baby this asshole like a little child. whatever happened to personal responsibility? he’s not crazy, he’s just stupid. he’s free to make foolish decisions. why should i prevent that? let’s face it, the vast majority of the world makes dumb decisions and we let them do it. he’s an adult. a dumb one, but i think that still counts.
and let me just say, that i think it’s bullshit that some idiot who shoots himself with a shotgun (i’m not entirely sure how he managed to do that), has to be coddled back to health while watching cable tv and sitting on his ass while nurses and doctors have to change his wound dressings several times everyday, wipe his ass, and record the amount of urine he makes every 8 hours. you think america doesn’t take care of the uninsured in this country? then how do you explain why this redneck asshole with no insurance is getting world class healthcare after trying to kill himself? how do you explain how someone with no insurance has been staying at my hospital for 90 days getting huge operations, skin grafts, tube feeds, TPN, cable tv, and all that shit? if we didn’t treat uninsured people, i wouldn’t have spent all those nights smelling all the rank ass shit coming out of someone’s bowel fistula, obsessing over how much potassium she has in her blood, how many calories she’s getting in her TPN, how much urine she’s made, how well she is working with physical therapy, what types of stepdown places will take her without insurance, or write a note on her (non)progress for 30 god damn days. hell, i wouldn’t have had to deal with over half of these uninsured dipshits who drink like 20 shots and play chicken with a tree on the side of the road. i would have had time to eat at least once a day, actually take a piss more frequently than every 12 hours, and had time to read and actually learn something other than the doses of morphine, dilaudid, and fentanyl.i don’t know if it’s karma or irony, but the last night was terrible. everyone and their grandma complaining about their pain. it’s like it was half strength morphine day and no one let me know. got to the point where i was trying to figure out the half life of morphine and compare it to the point where respiratory depression starts to kick in.
consider the patient who got a lysis of adhesions, post op day 1, on dilaudid PCA, toradol, and fentanyl. i get notified she’s in severe pain. i go see her and she’s there just bawling her eyes out. i’m like wtf, does she have bowel leak? then i remember she only got LOA. ok, does she have another small bowel obstruction? well, she’s been NPO and getting NG decompression for 24 hrs before her LOA, so that’s doubtful. puzzled, i ask my chief resident for advice. she’s like, i dunno, bump her pain meds up.
seems easy on first aid for step1 or step up to medicine. increase meds, sure, ok. so i give her a one time bolus of dilauded on top of her PCA, toradol, and fentanyl. i come back an hour later… “did it do anything?” her: “i sort of felt it but now it’s worn out”. at this point i want to put this chick on a vent, max out dilaudid and transfer her to the ICU. but one last try. i double the dose on her PCA and cross my fingers. i didn’t hear from her again that night, which is good because i pretty much stopped caring.
at the same time this was going on, some other chick from a car crash was complaining about muscle spasms and pain. which was reasonable because she cracked her hip. muscle spasms huh… how about some vencuronium, vent, and transfer to ICU? well, even though retiring from medicine at 27 seems appealing, i wasn’t self destructive enough to get myself fired that night, so i did what i’ve been doing all night. increase her morphine. of course there was only one problem. i didn’t know that she took dilaudid and loratab everyday at home. no wonder i kept getting paged about her still complaining of pain. yikes. how much dilaudid can you give again? i don’t remember how much i gave but it was an assload. stopped getting paged about her too, eventually.
i think half the patients on the service were actively complaining about their pain that night.
i don’t think i’m too much of an asshole. i’ve been nice to every single one of my chronic pain patients. i didn’t always give them all the pain control they wanted, but i figure if you get into a car accident, you shouldn’t expect to be pain free. that’s just not realistic. and i sure as hell don’t want their sorry ass getting pneumonia, because that would require me to fill out tons of useless paperwork for every day that they’re sitting on their ass getting antibiotics.
it’s weird being called doctor. i haven’t decided yet if this is a sign of respect or sarcastic patronizing, especially since i make no pretense about not knowing what the hell i’m doing. it’s either “let me look up the dosing” or “let me ask my senior”. it’s weird because during med school, i always heard the residents called by their first names. but here they all call me doctor. maybe that’s the way it’s done in these parts.
my job as an intern (a “real” doctor, mind you) is awesome. i have the pleasure of sticking my finger up a stranger’s butthole and sticking a plastic tube into someone’s peehole. it’s funny comparing adults and pediatric trauma patients. pediatric trauma patients will do everything in their power to prevent someone doing a rectal or foley. i remember this one 14 year old guy started to cry, as if getting a rectal was like getting raped, and this would turn him gay for the rest of his life. he clenched his buttcheeks so hard he could have broken walnut shells.
that got me thinking… isn’t that what a normal person would do? it’s amazing to me how adults allow doctors to do all these things to them. they barely even protest. i wonder what their experience in the hospital has been like; they’re trauma victims, so they don’t necessarily have an extensive medical history. what is it about adulthood that makes them so resigned to let the doctors do things that a teenager would do anything to avoid? i’m pretty sure it’s not better understanding of what needs to be done, because, frankly, i don’t give my trauma patients that much credit. i think it has something to do with being constantly beat down by society. subclinical learned helplessness i think is ingrained in virtually every american citizen.
a lot of people say there is a steep learning curve during internship, and you know what? they’re absolutely right. there is a huge learning curve… about narcotics. after about a half a week of working, it seems like i’m on a narcotics internship instead of a surgical one. seems like i write for narcotics more than morning labs. oxycodone, percocet, morphine, dilaudid, roxicet, fentanyl… is there any narcotic i haven’t prescribed yet? i understand people are in pain, and that sucks. but at the same time, i hate them and i wish i could just load them up on pain killers so they would go to sleep and just shut the fuck up. and having had night call, i had a pleasure of taking phone calls from drug seekers about their “lost prescriptions”.
internship just sucks ass. in an ideal world, i would write an order for a chest xray. it would actually be done, and i would be notified when it was available to see, and the attending radiologist would go over it with me when i wanted. but i work in the real world, and working in the real world is infinitely more painful.
1. make box to order chest xray
2. order chest xray
3. shade half a box to signify having ordered the chest xray
4. wait 2 hrs
5. go to chart to see if order was faxed to radiology
6. wait 1 hr
7. call radiology to see if they got the order
8. wait 30 minutes
9. call radiology to ask when they will take the xray
10. get tired of waiting, write chest xray STAT (costing hundreds of extra dollars for shit people should be doing quickly anyway)
11. xray done
12. wait 1-2 hrs for xray to show up on stentor
13. look at cxr
14. let senior resident know about cxr reading
15. wait 2-4 hrs for final read from attending
16. let senior resident know about final cxr interpretation
17. check off rest of the box indicating cxr was ordered and read
18. write note about xray findings on sign-out sheet
19. write note about xray findings on tomorrow’s progress note
20. write note about xray findings on tomorrow’s rounding list
21. write note about xray findings on the trauma tertiary survey form
the best thing about internship is spending the whole day obsessing over other people doing the work they’re supposed to do, 1) because you don’t trust them 2) because if they don’t do their mcwork it’s your ass on the line 3) patients suffer if people who don’t give a shit don’t do their mcjobs.
the second best thing about internship is documenting the hell out of everything onto four, five, sometimes even more pieces of paper, because hospital computer systems are total shit.
the third best thing about internship is getting paged about someone’s pain, seeing that they are on fentanyl and morphine, and it isn’t “touching them”, and writing for dilaudid. and then having to increase the dilaudid. and then finally giving up and giving them dilaudid PCA even though we’re supposed to “normalize” patients to get them the hell out. and hoping they push the PCA enough times to go to sleep and stop bothering me for the rest of the night. then getting paged about a phone call from someone who was recently discharged and lost their narcotics. then having them ask to talk to the attending because i won’t give them more narcs for them to sell to their friends. then writing for narcs anyway.
there’s some irony in how painful internship already is, and that i’m prescribing all these narcs all the time. but i didn’t major in english and i’m lazy.
thankfully 4th of july was unexpectedly quiet. and there’s free chocolate milk in the resident’s fridge. i do love chocolate milk.
the other day we rounded on this patient who had her own clothes on in bed. “i feel like a human being again”. i was like, yeah that’s great. what about me? i’m still in my scrubs and been working the night shift for a week.
the last few days before indentured servanthood
sometimes the more you think about medical “economics” the more you think The Flood was a good idea. i mean does it really make sense for someone to graduate with a 6 figure debt and virtually no practical skill whatsoever? we’re not talking about a school that leads to a job where no practical skills are necessary. we’re talking about being a doctor. i mean what could be more practical than being a doctor? doctors affect people’s lives, their health, and if we screw up, patients can die. and yet we graduate with our practical skills limited to… not crying when we get yelled at, performing rectal exams, and reading a bunch of numbers from a patient’s chart. i don’t see how anyone thinks it’s a good idea to go from making no decisions affecting someone’s health, to suddenly making a lot of them.
i suppose the only rationale i can see for making smart people deeply indebted and lacking in any real practical skill is to force them into residency. i mean, if we learned something valuable, that we could actually use in the real world, how many of us would go into residency? it’s not like residency is a very appealing path for us. 80 hr workweeks (if we’re lucky), 40k salaries, 100k+ debt… yeah, sign me up.
i don’t appreciate the fact that a PA or NP can earn more than a second year resident, or even a fellow. i think PA or NP should earn more than interns. let’s face it, interns are stupid and dangerous. but by the end of the year, i think they catch up real fast. so why do midlevels earn 60k or even 80k, while the second year resident is stuck at 40-45k? why is the surgery fellow, who has finished at least 5 years of general surgery, earning less than someone with a 2 year masters degree? and to make things even more screwed up, why is a fully trained cardiothoracic surgeon, fresh out of residency, offered jobs that pay LESS than some physician assistants?
i realize doctors do earn more after training (unless they are heart surgeons, you know, the ones that suture tiny vessels into a beating heart and save lives), but does that mean that residents should be paid less per hour than some high school student working a summer job at the gap? other jobs have 40 hour work weeks, which, if my math is correct, is half of what residents work. and yet these other jobs pay twice as much. now i’m really using a lot of brainpower here, but that means we roughly get paid 1/4 of what other people earn.
that is insanity. i’d hate to sound like someone who has an inflated sense of entitlement, but come on. i don’t think i should earn much as an intern. but after that year of hell, most of us will become pretty competent, and will have practical skills exceeding that of people earning much much more than us. that to me, is unfair. when you have fully trained heart surgeons earning less than someone who writes discharge paperwork, it’s not very encouraging.
by the way i start on trauma. and i’m on call the first day. and on the 4th day, i get the joy of covering multiple surgical services for 12 terrifying hours. some say there are no atheists in foxholes. if i finish those 12 hours without praying for god to take my life, i will consider it a small victory.
