MedWorm.com provides a medical RSS filtering service. Over 6000 RSS medical sources are combined and output via different filters. This feed contains the latest items from the 'Cut On The Dotted Line' source. Wed, 12 Nov 2008 17:53:43 +0100 http://cutonthedottedline.wordpress.com/2008/10/27/turf-wars-revisited/ Sorry for the light posting, folks. Life is extremely dull these days. Which leaves more time to observe the political delicacies of the transplant service. Transplant is unique as a surgical specialty, in that it is a surgical cure for a medical disease. Normally, there’s no surgical role in diabetes, renal failure, or cirrhosis. But once the patient is sick enough to have a transplant, the surgeons and internists have to work together. Very closely. I don’t know how other places manage it, but nobody has ever defined, here, exactly who is in charge, although everybody agrees that I get to admit and discharge all the patients. There is a great deal of collegial conversation among the attendings (”I trust Dr. Smith, let’s do whatever he says;” “don&#8... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1911812 Tue, 28 Oct 2008 01:41:35 +0100 1911812 http://cutonthedottedline.wordpress.com/2008/10/23/attendance-records/ We had journal club earlier this week, the first one of this academic year that I haven’t managed to find an excuse to avoid. . . Ahem. Actually, I go to journal clubs and conferences religiously - in the truest sense of the word, since there is an exponentially higher chance of my getting to any given conference than to church that Sunday. (Come to think of it, M&M has an eerily religious quality to it: everyone always comes, and confesses guilt. . . absolution not to be had reliably, though.) I was the kind of student who could never skip class even when I knew for sure that the professor mumbled in a foreign accent, had never explained a concept meaningfully in his career, and would spend the entire class going over the first two pages of notes (out of 50). So now, even though... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1902365 Fri, 24 Oct 2008 01:15:52 +0100 1902365 http://cutonthedottedline.wordpress.com/2008/10/22/very-much-off-topic-and-alarmist/ This election madness is getting to the point that it’s infringing on the hospital. People keep blurting out comments on the election, or even diving into a complicated analysis of each state’s possible outcome and impact on the electoral college instead of the football calculations which usually occupy the guys. The attending tried to hold a discussion session on current therapies for some surgical disease or other, but was completely unable to restrain himself from explaining, instead, the great danger that a radical socialist president in complete control of both houses of Congress would pose to the nation. I, of course, joined in, and we exchanged rumors and speculations. The chief shook his head and insisted that he prefers not to think about such things. To be sure, I muc... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1902366 Thu, 23 Oct 2008 01:22:00 +0100 1902366 http://cutonthedottedline.wordpress.com/2008/10/20/grouchy/ Sorry, nothing much to report here. I’m functioning as the social worker again: sort out nursing homes, home care, jump through the different insurance companies’ hoops about how one qualifies to be allowed to take this or that medication. The nurses and case managers and I just shrug our shoulders and give up; it really doesn’t matter any more what the doctor says. We’re forced to prescribe and practice with our hands tied by bureaucrats with no medical training, but we’re the ones who will get sued if anything goes wrong. It won’t even necessarily take Obama getting elected and passing his socialized healthcare plan through a completely Democrat Congress to get me out of medicine; it’s not like I need a lot more excuses; but that would sure make ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1892253 Tue, 21 Oct 2008 00:35:39 +0100 1892253 http://cutonthedottedline.wordpress.com/2008/10/17/recovery-in-process/ Posting has been a little light due to a recent transplant marathon: one transplant after another, starting in the afternoon, and concluding the next morning. The best summary would be to say, that after doing so many of one procedure in a row, I knew the steps in my sleep - which was good, because that was what it was close to by the end. . . I still wasn’t able to satisfy the attending, who seemed to want to know why, twelve hours after he’d first told me I needed to improve a point of technique, it still hadn’t been corrected. (Saying, Sorry, right now I’m lucky to be standing up straight, and doing something at least functional with the instruments, can’t think straight enough to change habits right now, did not seem like a good idea.) (I sent the poor med... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1886885 Fri, 17 Oct 2008 20:45:36 +0100 1886885 http://cutonthedottedline.wordpress.com/2008/10/14/best-and-worst/ Some friends at church asked me what my favorite kind of surgery was. This blog has given me the bad habit of being frank about my job, so I said, “Vascular surgery, because if you miss a stitch, blood shoots up at the ceiling.” They were rather horrified, and began relating how they had been traumatized by dissecting fetal pigs in high school or college.  Note to self: There is a reason that most doctors never talk about their profession outside the hospital or clinic. From here on, even if people ask pointed questions and seem to be genuinely interested, I will say nothing. I will be a monument of discretion (yeah, right). Which brings me to my least favorite part, at least of transplant surgery: dissecting out the external iliac artery and vein using electrocautery. This wo... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1873336 Tue, 14 Oct 2008 13:03:54 +0100 1873336 http://cutonthedottedline.wordpress.com/2008/10/11/connection/ Some doctors have a great way of interacting with patients. They strike a friendly, humorous (when appropriate) note immediately, and the rest of the proceedings are just like a plain conversation. They can crack jokes that the patients find funny, and always have a wisecrack response to the patient’s jokes. This especially works for the young male residents, who pick up the inner city slang, and can speak that dialect without sounding fake. I’ve never been like that. I can be professional, calming perhaps; I flatter myself that I’m good at explaining the problem and the potential solutions in understandable terms. But camaraderie and humor are not my suit. So I was tickled today when I went in to talk to a patient who’d been giving the nurses a bit of a hard time,... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1871298 Sat, 11 Oct 2008 19:59:20 +0100 1871298 http://cutonthedottedline.wordpress.com/2008/10/08/fiasco/ Note to self: just because the recipe in the New York Times food section only has three ingredients and a cooking time of fifteen minutes does not mean that you will be able to make it come out looking like the picture. This arrangement for cooking potatoes in a frying pan looked simple, but clearly they were working with a much more expensive frying pan than I have. It might still taste good, if I can get all the charred bits off. . . after all only half the total amount of potato is burned. . .        (Source: Cut On The Dotted Line) Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1863263 Wed, 08 Oct 2008 23:31:18 +0100 1863263 http://cutonthedottedline.wordpress.com/2008/10/07/socialism-reborn/ Two conclusions for the night: 1) Obama is a smooth talker, but what he’s selling is nothing more than pure old-fashioned socialism, just barely warmed over. It’s unfair for CEOs to make more than schoolteachers? It’s unfair for Fortune 500 companies to make billions of dollars a year? That sounds good to middle and lower class Americans - if only we could get our hands on some of that money - but it’s economically wrong. Those CEOs and companies create jobs. Their wealth is not harming the rest of us. Economics is not a zero-sum game: one person making more money doesn’t necessarily take anything away from me. Two places to look for more facts about McCain: an NRO piece about Obama’s ties to communists and terrorists, and another piece documenting Obama... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1859936 Wed, 08 Oct 2008 02:11:14 +0100 1859936 http://cutonthedottedline.wordpress.com/2008/10/07/another-first-3/ For the first time, I was the one called in in the middle of the night for a case. On one hand, it threw off my schedule a lot more than I’d expected. I’ve always told myself that getting up at night would be ok, because there’s such an adrenalin rush in the OR that I would wake up and be fine. We were partway through the case before I felt anything like that. I guess the excitement was more associated with novelty than I realized, and now that scrubbing on a case as the primary resident is becoming more routine, I can’t count on that energy for the middle of the night. On the other hand, I feel like more of a surgeon than I ever have before, and it’s wonderful. A lot of it is due to the great attending I’ve been working with. He lets the resident, even ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1859937 Wed, 08 Oct 2008 00:04:24 +0100 1859937 http://cutonthedottedline.wordpress.com/2008/10/06/really-old-fashioned/ Can I remark again how absolutely infuriating I find it, that the surgeons’ lounge here is inside of the men’s locker room? Infuriating, and humiliating by how completely everyone overlooks the fact. This is why you -me, actually; the guys don’t have this problem - can never find most of the attendings, or senior residents, between cases: but the two women attendings, and the female residents, will always be found standing by the OR desk (or wandering the ICUs), because we have nowhere else particular to go. (And please, now is not the time to discuss my theoretical inconsistencies. I might throw something. . .)        (Source: Cut On The Dotted Line) Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1856636 Mon, 06 Oct 2008 17:22:44 +0100 1856636 http://cutonthedottedline.wordpress.com/2008/10/05/non-dominant-inheritance/ I’ve written before about acquiring my father’s knack for memorizing all the hospital’s phone numbers (due to getting paged so many times). He has another skill which it might have been healthier not to acquire. When driving in the car, in addition to his penchant for passing with really minimal leeway, he also likes to dial his cell phone . . . while turning corners, and sometimes while passing. My father’s passengers quickly adopt a fatalistic mindset. He’s had remarkably few accidents, for all this. Now I also am an expert at palming my beeper one-handed, reading it, and dialing my cell phone while driving. I really ought to stop. . . but the reflex to answer the page quickly and make sure it’s not something serious is simply too strong to overcome. ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1853934 Sun, 05 Oct 2008 23:22:42 +0100 1853934 http://cutonthedottedline.wordpress.com/2008/10/04/prescience/ Driving home from the hospital, I got stuck in traffic around a recent accident. Sitting and waiting, I calculated that from the amount of debris on the road and the number of flashing lights involved, it must have been a fairly serious accident, which would mean a good likelihood that at least one person involved would show up as a trauma alert somewhere. And only five minutes from my hospital. . . Two minutes later the trauma pager started going off, describing that accident. Not sure what the moral of that is; maybe not to carry a trauma pager when I’m not on trauma call. But it was fun to know more than anyone else in the traffic jam about what was going on.        (Source: Cut On The Dotted Line) Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1852769 Sat, 04 Oct 2008 18:05:01 +0100 1852769 http://cutonthedottedline.wordpress.com/2008/10/03/cowboy/ I think I mentioned before that, along with being the insane Christian conservative of the hospital, and being too polite to be a surgeon, the other residents tease me about doing procedures on anything that moves - or doesn’t move, more accurately. Today I blew my last chance of pleading innocent. Being at loose ends (as seems to be usual for me on this rotation), I was just wandering around the ICUs to see what kind of trouble other people were having, and maybe cheer myself up that I wasn’t having to take care of those problems. I found a couple lines to put in - various people having too many things to do at once, needing to be in the OR, etc, so I volunteered to put in their lines. The guys found me apparently lost in the MICU, in the middle of a real mess. “What&#82... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1851387 Sat, 04 Oct 2008 00:21:23 +0100 1851387 http://cutonthedottedline.wordpress.com/2008/10/01/learning-without-talking/ It seems like my dry spell is at an end, and I’m starting to have my hands full of transplants. Which leads to another topic: The only thing that surgery residents love more than gossiping about each other is critiquing the attendings. I’m not really into that. (Or maybe refighting the dramatic cases; that might be the top pastime.) I learned to do calculus and chemistry and anatomy and biochem by not questioning the teacher’s assumptions. I know that doesn’t sound scientific, but I used to ask “why?” or “how do we know that?” so much that I could never get to the main point of the lesson. So I stopped. I tried to jump into the subject: assume that all the axioms the teacher grants are correct, let’s see how it works. Same thing with s... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1845274 Thu, 02 Oct 2008 01:13:32 +0100 1845274 http://cutonthedottedline.wordpress.com/2008/09/30/time-warp/ Surgery residency is nearly twice as long as that of any other specialty: Five years, compared to three for medicine, pediatrics, and ER. (Neurosurgery is seven, radiology and anesthesiology five total.) This leads to some interesting relationships between junior and senior residents, and between specialties. For example, as a second-year resident, I am as far behind my fifth-year chief as a medical student is to a senior medicine resident. They’re polite enough to treat the juniors as colleagues, though not equals, but the knowledge gap between us is as wide as between me and a second-year medical student. The more I consider this gap, the more amazed I am at their tolerance for my shortcomings. With medicine and ER residents, it works the other way. The doctors who were medicine an... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1841472 Tue, 30 Sep 2008 23:26:35 +0100 1841472 http://cutonthedottedline.wordpress.com/2008/09/29/prejudice/ A few hours into a busy morning - the kind that always develops when, building on a string of slow days, I have a stack of journal articles to read and paperwork to do - I got a nonsense consult. Nonsense as in, all the surgery attendings in the hospital already knew about the patient, and had discussed her condition at length and leisurely among themselves. As a result of this consultation, spread over three days, they had decided that the one attending should officially consult the other attending. Which means his resident, that is, me, needed to go put an official note in the chart to let the poor medicine team which was babysitting this patient know that the surgical attendings have changed. So my seeing the patient and writing a formal consult was going to contribute absolutely nothin... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1837785 Tue, 30 Sep 2008 01:41:27 +0100 1837785 http://cutonthedottedline.wordpress.com/2008/09/27/foreshadowing/ It’s amazing how much the responsibility for presenting at M&M [morbidity and mortality conference] concentrates the mind. Now I’m not just worried about the patient as a person, and about my role in events; now I’m also trying to avoid having to present a complication/mortality, and then trying to figure out how on earth I’m going to explain this one. So far I can’t come up with anything even halfway presentable; it’s going to be a miserable morning when my turn comes around. No wonder the seniors look so disturbed when complications develop.        (Source: Cut On The Dotted Line) Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1834875 Sun, 28 Sep 2008 00:44:08 +0100 1834875 http://cutonthedottedline.wordpress.com/2008/09/26/mars-and-venus-in-the-or/ One of the attendings, explaining his decision to hire a female partner, remarked, “Women make better surgeons, honestly. They have more natural dexterity.” All the women in the room waited for the inevitable other half of the comment. After a pause, he continued, “The only thing is, they can’t concentrate. Guys, when they’re doing something, think only about that one thing. Women, their minds are all over the place. When we operate, we’re not thinking about the laundry that needs to be done, what we’re going to have for dinner, what to do with our hair, and so on.” Laughs all around. So I’ve been trying to analyze ever since my concentration in the OR - which of course is impossible. My conclusion is, that I do multitask all the time. ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1833605 Sat, 27 Sep 2008 02:17:08 +0100 1833605 http://cutonthedottedline.wordpress.com/2008/09/24/a-little-better-2/ Finally, some action. Went on a donor run with an attending I haven’t worked much with before. My main conclusion from this is, that the popular conception of surgeon’s hands as delicate is quite wrong. The attending handed me about eight liters of ice to break up (to pack into the abdominal cavity to cool the organs after cross-clamping), and instead of, like other transplant surgeons I’ve worked with, growling in frustration after watching me for five seconds and taking over, left me to finish the job by myself. Which was salutary, but painful. Between the ice and the hammer, and then tying knots in nylon afterwards, my hands are all scraped up, and my arm is going to be sore for days. I need to take up weightlifting. The surgeon not knowing me was also nice because he ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1826466 Thu, 25 Sep 2008 01:23:28 +0100 1826466 http://cutonthedottedline.wordpress.com/2008/09/23/still-bored-2/ Still nothing medical to write about. I spend my days doing social work and case management. I’ve gotten really good at sitting in patients’ rooms, taking the time to actually sit in a chair (which certainly does lend a more relaxed air to the conversation), and listening to all kinds of details about their lives which are not medically related. This makes me feel like a good person, and hopefully is giving me practice at establishing rapport with people. I haven’t done some of this stuff since medical school. It makes me feel like a bad surgeon. Why do I not have anything else to do with my time? A surgery resident is doing something wrong if they are not busy. I keep going through my list looking for something to do, and except for the occasional consult (who now gets t... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1826467 Wed, 24 Sep 2008 01:51:26 +0100 1826467 http://cutonthedottedline.wordpress.com/2008/09/22/arent-scrubs-wonderful/ Surgery is a great field for a fashion-challenged person such as myself. On any given day, there is one easily-obtainable set of clothes which will fit in perfectly with everyone else and be completely appropriate for any occasion, ranging from early morning rounds to professor rounds to clinic time to the OR to emergencies on the floor or in the ER. On the rare occasions when more formal attire is required (some professors’ rounds, when giving speeches, etc), this is usually clearly spelled out ahead of time, due to the propensity of both male and female surgery residents to wear scrubs whenever they have not been instructed otherwise. There was one program which I liked when I interviewed at, but I got a clear indication that it was not for me when one of the residents mentioned t... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1816077 Tue, 23 Sep 2008 01:30:42 +0100 1816077 http://cutonthedottedline.wordpress.com/2008/09/21/internal-accountability/ Last year I got used to the idea that I was responsible for what the medical students did. I was supervising, so it was always my problem. If I hadn’t noticed what they did, that was my problem too. “My problem” is getting bigger this year. Now I’m responsible for the interns too. If we’re on the phone, and I don’t ask them for some information, the fact that neither of us knows it is my problem because I should have asked, not theirs because they didn’t check in the first place. If I tell them to do something, and it doesn’t get done, it’s my problem, because I should have checked back on them. If they misorder something, it’s my problem, because I should look at their orders. Human nature likes to blame other people. It’s ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1812989 Sun, 21 Sep 2008 15:57:15 +0100 1812989 http://cutonthedottedline.wordpress.com/2008/09/21/te-deum/ Another magnificent piece of music: Haydn’s Te Deum, which was performed for a visit of Admiral Nelson to the Austrian court in 1800. It can be sampled (and even better, acquired) here. This ancient hymn is glorious in itself, and Haydn’s triumphal score sets it beautifully. Some great lines: Te Deum laudamus, te Dominum confitemur. We praise thee, O Lord; we acknowledge thee to be the Lord. Te aeternum Patrem omnis terra veneratur. . . Thee, the Father everlasting, all the earth doth worship. . . Te gloriosus apostolorum chorus, te prophetarum laudabilis numerus, te martyrum candidatus laudat exercitus. . . Thee, the glorious choir of the apostles, Thee, the admirable company of the prophets, Thee, the white-robed army of martyrs doth praise. . . Tu rex gloriae, Christe. Th... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1812990 Sun, 21 Sep 2008 15:35:13 +0100 1812990 http://cutonthedottedline.wordpress.com/2008/09/20/auto-hypnosis/ When I was a medical student, and had nothing to do but shadow attendings, it usually took me less than a day to memorize their stock phrases: lines of introduction, questioning, explanation, even pleasantries, jokes, and stories, that they tended to repeat to every single patient, with very little variation. It bored me to tears, because every single doctor had his own set of phrases that he repeated all day long to every patient. To the patients it was new, but since I could have recited it myself, having to listen to it for four weeks was maddening. I promised myself I would never fall into such a rut. One year and three months in, I listen to myself on morning rounds, and I’m boring myself. This is bad. I know why it is, though. At first, I was so shy about walking into people&#8... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1811621 Sat, 20 Sep 2008 23:39:43 +0100 1811621 http://cutonthedottedline.wordpress.com/2008/09/18/warning-rant-ahead/ I thought WhiteCoat’s story about medical professionals not having heard about Medicare’s new strategy to avoid paying healthcare professionals for services rendered (otherwise known as the “never” events) had to be an exaggeration. Then I mentioned their upcoming enforcement (next Wednesday, Oct. 1) to a senior resident, and he gave me a blank stare. He seemed to think this was another piece of raving insanity, along with my defense of Palin (what can I say? when all the men in the room start attacking her, I morph into a Republican) and my objections to abortion. It took me quite a lengthy explanation to get him to think I might be right - this despite signs all over the medical records department warning physicians of the events that are now not permitted to occu... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1806681 Fri, 19 Sep 2008 02:39:50 +0100 1806681 http://cutonthedottedline.wordpress.com/2008/09/16/loose-ends-2/ I’m bored. I’ve resorted to two strategies which are the resident’s equivalent of standing on a bare hill in a thunderstorm and holding a piece of metal: strolling through the halls discussing how bored I am and how much I would like anything at all to happen, and sitting in the nurses’ station rather conspicuously napping, reading a sci-fi novel, and following political commentary on National Review, which is pretty much begging for the nurses to decide I don’t have enough work to do, and to come up with some for me. They didn’t. All that happened was I got tired even of the novel (not as good as the book it’s a prequel to), got tired of reading about Obama and Palin, and was forced to read a chapter of Greenfield online in order to stay awake. M... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1798665 Wed, 17 Sep 2008 00:40:04 +0100 1798665 http://cutonthedottedline.wordpress.com/2008/09/15/3am-phone-calls/ This whole home call concept takes some getting used to.  One of the major lessons I learned last year was how to be on the spot: if a patient’s sick, you don’t wait to get called, you keep walking by. If you do get called, you give some preliminary orders (oxygen, fluid, ekg) on the phone, and then get over there so you can see for yourself. And you don’t leave in five minutes; if there’s nothing else urgent, you stay around to see how things go; work on the computer, make some calls, but stay handy for a little bit. And of course the cardinal lesson in medicine: trust no one, neither those junior to you nor those senior. Everyone lies; verify it for yourself. Now I have to reverse that. I’m getting a little better at jumping wide awake in the middle of the ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1794928 Tue, 16 Sep 2008 00:04:34 +0100 1794928 http://cutonthedottedline.wordpress.com/2008/09/14/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 winn... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1791817 Mon, 15 Sep 2008 02:23:27 +0100 1791817 http://cutonthedottedline.wordpress.com/2008/09/11/love-in-action/ Another thing I need to learn to be a real surgeon: When doing an open abdominal case on a patient who’s had practically any previous operations, there are bound to be adhesions to some extent (unless they’re on chronic steroids, in which case you get the prednisone effect - wonderfully smooth going in, and the near-certainty that they won’t heal afterwards). Depending on how many surgeries and where, and the patient’s genetic tendency toward scarring, there will be more or less adhesions, and it will be more or less difficult to get where you’re going. When dissecting the adhesions apart in order to get to the underlying structures, you have to protect the bowel somehow. Touching the intestines with the bovie (electrocautery) is very much frowned upon, and c... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1786297 Fri, 12 Sep 2008 02:36:08 +0100 1786297 http://cutonthedottedline.wordpress.com/2008/09/10/still-not-medical/ At loose ends lately, I’ve been exploring some of the food blogs (Just Food, Japanese Kitchen, Gourmet Traveller, and Greek Food, to name a few). These have a few effects on me: 1) tempt me to buy exotic ingredients that I have no real need/use for in order to try some of their recipes 2) inspire me to cook more real food at my house. I would even consider trying some food blogging of my own, except I have no camera, which seems to be an essential part of the genre, and after all, my cooking is of a very mundane variety, only interesting because I’m reinventing the wheel by discovering it all on my own. Some lessons learned: Baking cakes is dangerous. Either you have to take the whole thing to work, in which case the nurses are thrilled, and make such loud comments that the att... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1783154 Thu, 11 Sep 2008 02:09:22 +0100 1783154 http://cutonthedottedline.wordpress.com/2008/09/09/parenthetical/ Sorry folks, nothing useful to say. I’m going through another disillusioned-and-bitter phase; judging by precedent, it shouldn’t last more than a few days. Will return with regular programming then. (The funny thing is that, even though I feel depressed and bitter and cynical, I’m still known for being cheerful and optimistic. The chiefs are still telling me, “Wait a few years and see if you’re still so happy about everything.” I feel like I’ve turned into all the cynical surgery residents I knew as a medical student, but apparently it doesn’t come across that way - yet. I guess that concluding every consideration of a patient’s worsening symptoms and grim vital signs with the hope that they could still turn around in the next two days ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1780004 Wed, 10 Sep 2008 02:02:07 +0100 1780004 http://cutonthedottedline.wordpress.com/2008/09/08/perspectives-2/ I got to the evening service yesterday, and spent some time chatting with other young people afterwards. Or, to be more precise, listening to them chatting, since I only have one topic of conversation these days, and I try not to impose it on people outside the hospital. They were discussing how long an 8-hr business day is compared to a day of college classes, and how much longer a 10-hr day is, when they get really busy and the boss makes them work late for a day or two. I was laughing to myself. We residents work six hours on a weekend day, and consider that we have the day off. We work 13-14 hours, and are happy to get home at a reasonable time. 15 is annoying, but it comes with the territory. I really had not comprehended what life is like for people who pick a more normal career. 8 ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1775931 Mon, 08 Sep 2008 23:54:41 +0100 1775931 http://cutonthedottedline.wordpress.com/2008/09/07/dixit-dominus/ I didn’t make it to church this morning. I’m feeling almost guilty about it, I don’t know why. I thought for the first time in six weeks I’d get there. I even dressed up before going to the hospital, just to be efficient. Then the attending was late, some patients were more complicated than expected, and a teammate got stuck in the OR and I had extra work to do. . . I could have rushed out, but it would have been irresponsible; there were labs to tidy up, orders for tomorrow to put in, and it takes time to sign out properly to the on-call team. So I didn’t make it. I’ve been listening to this CD non-stop for the last several days; one of my absolute favorites: Chanticleer’s Mexican Baroque. The best tracks are a setting of Psalm 110, which was one ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1773422 Sun, 07 Sep 2008 14:59:07 +0100 1773422 http://cutonthedottedline.wordpress.com/2008/09/06/literature-recommendation/ Quick note to say how much I’m enjoying Greenfield’s chapter on liver anatomy. This was previously a closed book to me, and whenever anyone started discussing liver anatomy/resection/any surgery coming close to the liver (which unfortunately includes a lot of surgeries), my eyes would glaze over, and I would start gazing at a point in the middle distance, hoping they would get through it before it occurred to them to ask me a question. No more. I have finally grasped the eight hepatic lobes, and why lobe 1 is in the back, and lobe 7 is off in a corner. This is fairly significant, since most pictures of liver anatomy show the eight lobes split off, as though a 3D animation is about to start, with all kinds of spider-like connections between them. Since there are four flow system... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1770816 Sat, 06 Sep 2008 19:50:20 +0100 1770816 http://cutonthedottedline.wordpress.com/2008/09/06/laid-back/ I’m having a great time with transplant. Still haven’t really had much in the way of surgery to do, but with the whole weekend ahead, I’m hopeful that something will turn up. Otherwise, this is great. Some surgery residents dislike transplant, because you have to do so much medical management (by definition, a transplant patient has lots of serious medical problems - diabetes, difficult-to-control hypertension, history/risk of strokes, cardiac problems, liver dysfunction), and because they regard this rotation as a waste of time, since so few residents actually consider transplant as a career. I don’t know what they’re complaining about. I don’t want to do transplant (it has to be the worst lifestyle outside of neurosurgery: completely unpredictable, wit... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1770817 Sat, 06 Sep 2008 15:02:20 +0100 1770817 http://cutonthedottedline.wordpress.com/2008/09/04/a-peek-at-politics/ In the absence of any medical subjects of interest to write about, I’ll throw in my two cents worth about Sarah Palin: As someone who determined from the minute his name was mentioned that I would never vote for McCain - I’m impressed by his VP choice. I don’t think it’s enough to make me vote for McCain (if you read this blog, you’ll know that I’m too far off the ultra-right wing/libertarian side to like his straight-down-the-middle politics), but Palin is certainly enough to make me think two and three times. She knows an easy solution to the rising gas prices (drill in ANWR; why do we have to give all our oil money to the Arabs?); she supports gun rights; she’s lived out the pro-life commitment to the value of all human lives (keeping a Down&#82... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1764446 Fri, 05 Sep 2008 02:06:22 +0100 1764446 http://cutonthedottedline.wordpress.com/2008/09/03/stepping-back/ My patient is dying (again), and I can’t do anything to stop him. That’s such a horrible feeling. I can’t help him. I can’t stop the disease, I can’t change anything anymore. It’s too late. At that point, the thought arises, if I can’t cure him, at least maybe I could make this quicker, easier for him and his family. I never thought I’d understand (dare I say sympathize with) that idea. I understood today, finally, how doctors, whose purpose is to heal, can end up wanting to kill (because that’s what euthanasia is, in the final analysis). I wanted to do something, anything, for this man; and if I couldn’t fix him, that left only one thing. The problem is that I’m not God. There’s a very old joke about the difference be... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1760354 Thu, 04 Sep 2008 01:55:26 +0100 1760354 http://cutonthedottedline.wordpress.com/2008/08/31/at-last-2/ Done with trauma! It only took me three extra hours to get out of the hospital in the end, which I was kind of resigned to, considering it’s the middle of Labor Day weekend (a fact I only realized when the ER staff started commenting on the number of people who started their drinking spree early, and thus showed up in the ER earlier in the day than usual). In addition to the usual deluge of traumas at the nominal signout time (nominal, because there’s a better than 50% chance that something major will happen five minutes before or after), I felt like I had to stay and tidy up every single loose end on my patients before I could leave, since I won’t be back to fix it tomorrow. I won’t be back to fix it tomorrow. I’m not even going to look in the direction of tr... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1750596 Mon, 01 Sep 2008 01:27:11 +0100 1750596 http://cutonthedottedline.wordpress.com/2008/08/30/hit-the-green-button-please/ The beeper is an amazing object, and whoever invented it ought to be relegated to one of the lower circles of the Inferno. (On second thought, remembering in the books the old paging system, overhead, which must have been infinitely more painful, perhaps a middle circle would be adequate.) This time of year, on a sunny Saturday, the trauma pagers go off with predictable regularity: five minutes after signout in the morning, and five minutes before signout in the evening, and every forty-five to sixty minutes in between. There’s kind of a reflex shrug we’ve all developed, standing in a circle in the unit, when the combined beeps and twitters and buzzes of our pagers, and the charge nurse’s pager, and the respiratory tech’s pager, all go off at once. Some people try ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1747285 Sun, 31 Aug 2008 02:14:10 +0100 1747285 http://cutonthedottedline.wordpress.com/2008/08/29/the-end-is-near/ No dramatic events. I am one day further along in my quest to escape from the trauma ICU before any permanent damage is done. The nurses are a little puzzled by my excitement, and kind enough to say they’ll miss me. I guess, since they persist in calling me about every thing that happens on the unit, regardless of whether I’m following the patient or not. Flattering, and fairly safe, since I’ve now gotten better than I was at the beginning of the month at following what’s happening to all patients, whether they’re “mine” or not, but difficult to handle delicately: when to waste the nurse’s time by telling them to call a different resident, when to defer to another resident’s handling, when I wouldn’t have chosen that method mysel... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1743054 Sat, 30 Aug 2008 01:01:06 +0100 1743054 http://cutonthedottedline.wordpress.com/2008/08/28/procrastinating-3/ I started reading Greenfield’s section on transplant. It starts with a 30 page chapter on transplant immunology. It’s taking me about five minutes to read each page. This is going to take a long time. (There are the occasional hilarious comments, such as “Presumably, these multiple V region families arose by an evolutionary process of gene duplication followed by mutation of individual family members. . . the combinatorial possibilities are extremely large, showing why the immune system is able to generate antibodies for virtually all known antigenic determinants.” So they write this long chapter to explain how little they understand these cellular processes, but how miraculously well they turn out - the human immune system works against virtually every virus and ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1739649 Thu, 28 Aug 2008 20:17:51 +0100 1739649 http://cutonthedottedline.wordpress.com/2008/08/26/almost-done-2/ What can I say? Nothing much happened today. The sick people in the unit over the last week either died, or got well enough to leave. We’re left with a population which is overall more likely to get out and do well than we’ve had for the rest of the month. The month is almost finished, unattainable as that has seemed for so long. The next few months seem in prospect to be a little better. Certainly more opportunity for operating. The attendings I’ll be with have their own quirks, but not as wild as the trauma attendings, and more to my taste. (Surgeons who leap at every excuse to get in the OR are just more natural than surgeons who take every excuse to stay away from it.) I’ve been getting back in touch with some old med school friends lately. We haven’t talk... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1734443 Wed, 27 Aug 2008 01:17:40 +0100 1734443 http://cutonthedottedline.wordpress.com/2008/08/25/queasy/ I must have been looking disturbed. A couple of people, including the chief resident, asked me how I was handling the one patient’s death, and then stood still to listen to my answer. That’s the closest to those ‘debriefing’ things I’ve ever gotten (and I hope not to get any closer; surgeons don’t do well talking about feelings involuntarily). Just to have them ask was all I needed, and I told them I was fine. After all, in a way, when someone’s been deathly ill in the ICU for weeks, it’s a relief all around when they go. I feel kind of guilty, to be this relieved, but after all, they’re probably relieved to be done with the whole thing too. Except I’m fairly certain they’re in hell now (lots of Buddhist paraphernalia); in w... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1734444 Tue, 26 Aug 2008 01:02:05 +0100 1734444 http://cutonthedottedline.wordpress.com/2008/08/24/useless/ A patient I’d been taking care of all month died today. Like before, I wished I could join the family in their mourning, but that wouldn’t be right. I’m not really part of it, and they need their space. I didn’t know him when he was alive and a person, only when he was living on a ventilator with us sticking needles at him all the time. I didn’t even know any good words to say at all. “I’m sorry” - but you can’t go repeating that forever, and I couldn’t think of much else. I’m sorry, I tried to stop him leaving; I’m sorry, if I could undo this I would; I’m sorry, we’re not miracle workers after all. Failing that, I wanted to go sit in a corner and not talk to anyone else. Talking to the coroner, always so ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1734445 Mon, 25 Aug 2008 00:08:08 +0100 1734445 http://cutonthedottedline.wordpress.com/2008/08/23/dissatisfaction/ I hate it when my patients die. I spend hours and days afterwards going over every single step, everything I did, everything that happened - was there anything I could realistically have done differently? There always is, and I can never tell which differences would be important, and which not. I also hate the 80hr week. For the first time this month it is seriously forcing me to spend less time in the hospital than I want to. Other times I’ve gotten around it, but this month it’s getting me in trouble (surprised?). I’m being forced to come in to work later than I’d like, and leave earlier than I want to. I feel like I’m not taking good care of my patients. That was the only good thing I had, satisfaction in doing my job well and taking care of my patients; no... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1729756 Sun, 24 Aug 2008 01:43:22 +0100 1729756 http://cutonthedottedline.wordpress.com/2008/08/20/sidetrack/ The day was going relatively better (I now have myself persuaded that it’s only a week till the end of the month, and a week can’t be that bad), until I ran into some serious bureaucratic problems, better not addressed here. Tomorrow I’m going to be in trouble. . . So we’ll take a commenter’s question about sick days instead: I think there’s something in federal work regulations somewhere about employees being allowed a couple sick days off a year. I suppose they would be obliged to let us if we asked. I wouldn’t know, that kind of thing is frowned upon among residents. I’ve known one of the other surgery residents to be so sick she had to run out of the OR to throw up, and then stay till the end of the day. I had one day where I drove home f... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1720677 Thu, 21 Aug 2008 00:13:32 +0100 1720677 http://cutonthedottedline.wordpress.com/2008/08/19/slough-of-despond/ Halfway through rounds the medical students were asking me if I was all right. There was nothing wrong, just the insanity of the trauma unit, and my dysfunctional method of communicating with the chief and the attending. The chief and I have a very strange interaction; we like each other, and it’s certainly better when he’s around and responsible for things instead of me, but somehow he makes a day in the trauma unit even more complicated. So the students are trying to help me, and I don’t even have the energy to be polite to them. All I can remember is the resident I knew when I was a student, trapped in the unit for months on end. He didn’t talk to students much either, although in my memory he was still more helpful than I’m being. That’s bad, because... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1717882 Wed, 20 Aug 2008 01:16:09 +0100 1717882 http://cutonthedottedline.wordpress.com/2008/08/18/enough-is-enough-2/ I’m tired of trauma. I feel like I’ve been doing this forever, and it’s going to keep going forever. Every day starts out ok, and then goes on for a whole lifetime, with twenty lives in my hands, and thirty or forty people wanting something from me (ranging from the medical students wanting something educational or useful to do, and I don’t have the time I owe them to be educational, to the nurses as usual reminding me of what their patients need, to the attendings wanting me to do a dozen different things, reminding me of things I know I should be doing, or asking me the same question for the third time in five minutes, to the families, who need to be talked to, and all want more time than I have). That is one thing I’ve figured out. I’ve decided which... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1714469 Tue, 19 Aug 2008 00:47:28 +0100 1714469 http://cutonthedottedline.wordpress.com/2008/08/17/geiser/ I’m not exactly sure how it happened while I was assigned to trauma, but I spent a lot of the day assisting with vascular-type patients. At one point in the ER, there were three or four residents trying to sort out an AV fistula - or rather, a patient with an AV fistula. The fistula, created and valued for having a lot of blood running through it, fast, under high pressure, had sprung a leak. And such a leak. I’ve seen lots of fistulas oozing persistently, or even enthusiastically. This one gushed continuously, despite a muscular young man having both hands clamped on it; and if anyone let go, it started shooting for the ceiling. The patient took this all quite calmly, until we were at the most delicate point of trying to get the first stitch somewhere near the hole, which nece... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1711927 Mon, 18 Aug 2008 01:36:41 +0100 1711927