Medicine consults

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

night at the museum

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

no guts no glory, right?

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.

flick of the wrist

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.

masochism

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.