month 3 update: it still sucks

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.

boasting that my life sucks a little less than before

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.

ain't life grand

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.

oh the pain

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.

playing nice

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.