MedWorm provides a medical RSS filtering service. Over 6000 RSS medical sources are combined and output via different filters. This feed contains the latest medical blog items that have been tagged with 'internship'. Sat, 03 Sep 2011 02:10:32 +0100 http://www.medworm.com/index.php?rid=5050629&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F07%2Fcongratulations-interns-of-2012.html The job offers have starting trickling in for next year's interns.I can't believe it was only one year ago that this was me. So much has changed since then. My career aspirations are still the same, but a lot of other things have shifted slightly sideways.So, to next year's interns, I can share with you some things that happened to me, and you may also experience in the first half year of your working life as a doctor:You will find your feet as a junior doctor. Granted, like me, you may spend the first couple of weeks absolutely scared out of your skull. But you'll get used to it and after a few months, you will manage to have some nights where you don't dream of clinical scenarios and ward rounds all night long . . .You will face challenges, both personal and professional, that you will o... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=5050629 Mon, 18 Jul 2011 10:38:00 +0100 5050629 http://www.medworm.com/index.php?rid=4968524&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F06%2Fthings-i-have-learned-during-internship.html A few brief extras, suitably random:a) Find a system that works for you. You may carry around a clip-board with printed notes, a card system in your pocket, some big plastic box with everything you will need should there be a mini-apocalypse at the work station that wipes out all of your request forms, an iPad or just a scrap of paper that you keep in your pocket with the salient information on it for the day.Feel free to change this at any point. Just don't lose all of your patient information and then have everything explode and fly everywhere in the middle of a busy ward round because you won't recover until later in the day and this will throw off your groove completely and not even a big cup of coffee bought for you by a sympathetic medical student will help.Also, what works for one r... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=4968524 Sun, 26 Jun 2011 09:57:00 +0100 4968524 http://www.medworm.com/index.php?rid=4968525&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F06%2Fand-onwards.html I have finished our second rotation of the year, and this was the one I dreaded the most - surgery. I like the idea of surgery and I can appreciate how some people love it, however I am not one of those people.I know what I like and surgery isn't it. I prefer taking my time with patients, having reasonable starting and finishing times and access to cups of tea and chairs when appropriate (yes, this is a little facetious, but it is the little things, right? ;) ). I like the sunshine, and I like vitamin D. I love seeing the patient as a whole person, and while there is a possibility for doing this in surgery, many of your relationships start and end within the space of a few hours and you get to say good-bye to the patient, having fixed their issue to the best of your ability.I met some abso... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=4968525 Sun, 26 Jun 2011 09:37:00 +0100 4968525 http://www.medworm.com/index.php?rid=4803169&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F05%2Fstrange-things-to-be-jealous-of.html . . . when you would rather not be on your way to work.1) The magpies by the side of the road. They get to be outside all day and leaping around on the grass. You get to be inside doing paperwork. 2) The people out on their morning walk at the crack of dawn, while you are already in your car on your way to work. They have more leisure time and will probably live longer lives.3) The person who cleans your house. Some days medicine is too stressful and you would rather wipe benches and clean toilets.4) The mother getting her kids ready for the school run in the morning. Because sometimes you question your life choices. 5) Your pets, who will still be on your bed when you have been at work for 6 hours and it will be at least another 7 hours before you are home again.6) Your spouse when he/she... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=4803169 Mon, 09 May 2011 09:51:00 +0100 4803169 http://www.medworm.com/index.php?rid=4797780&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F05%2Fpushing-through.html Yes, I'm still here.The current rotation I am on is quite demanding, and I am regularly clocking up more than 60 hours per week.Still, I am not over-tired and am learning quite a lot. Frankly, it would be hard not to learn.In a few weeks I am hopefully going to be 2/5 of the way through my intern year. In the Australian system, we enter a specialist training program after being an intern/resident for a year or more. This means we get to see a bit of areas that we have no interesting pursuing and theoretically get a well-rounded grounding as a doctor.There are a lot of advantages to this and only a few disadvantages. One of those disadvantages is that I am now too tired to type any more because this rotation is sucking a lot of time and energy out of me (but this is okay), so this is all I'... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=4797780 Sun, 08 May 2011 09:58:00 +0100 4797780 http://www.medworm.com/index.php?rid=4642622&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F03%2Fthings-i-have-learned-during-internship.html Three things this time:1) It seems that you get good and comfortable in a rotation, and then is time to move on and I don't want to move on from this one because I really like it. Also, the next rotation scares me.2) I am tired. A lot. Sometimes it seems like it is out of proportion to the hours I'm working, which aren't bad, but I know this tiredness isn't excessive. This happened last time I started to work full-time after uni. It passes. Slowly.3) Being looked down on as "just an intern" by patients is now amusing rather than affronting. I know I'm just the intern and I'm happy to have somebody else look after you if you don't think I'm good enough. It makes my "to-do" list a few items shorter. ;)And one extra thing that I already knew:I don't get a lot of time for blog posting, and the... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=4642622 Sat, 26 Mar 2011 11:31:00 +0100 4642622 http://www.medworm.com/index.php?rid=4554804&cid=t_122957_165_f&fid=36770&url=http%3A%2F%2Fmetaot.com%2Fblog%2Fprospective-ot-internship-back-work-opportunity-feedback-request Want to become an Occupational Therapist or get back to being an Occupational Therapist after some time out of the profession? Get in touch with us as we really want to hear from you………: We are trying to set up an intern opportunity for students wanting to get onto an Occupational Therapy course or returning to work OT’s who have been out of the profession for a while. The idea at the moment is that it will be a part time post designed to fit in around other work or study commitments and will be available on a regular, rolling basis. We are just planning this at the moment and would love your feedback about how we could design things to make them as interesting and beneficial as possible – You know what’s coming next I’m sure……so please get in touch and let us know your t... meta-ot blogs blogs http://www.medworm.com/rss/comments.php?id=4554804 Sun, 06 Mar 2011 14:01:06 +0100 4554804 http://www.medworm.com/index.php?rid=4482791&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F02%2Fthings-i-have-learned-during-internship_15.html I actually enjoy teaching (or trying to teach) medical students. It probably helps that it has been a very short amount of time since I was a student, so I remember what it is like. As a student, any time you get doing interactive learning of practical skills feels immensely valuable and helps keep you interested. Also, there are no "gunners" in the group of students who are on my ward, although they are all generally enthusiastic, so it is fun to tell them what I know and try to get them to start learning practical skills. Nobody has followed me into the bathroom yet, so all is well with the world. I guess that since I'm not the one marking them, they don't feel the need to impress me with their keenness at every opportunity. This results in a level of interaction where they are with me f... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=4482791 Tue, 15 Feb 2011 08:57:00 +0100 4482791 http://www.medworm.com/index.php?rid=4459982&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F02%2Fnew-blog-to-follow.html A previous commenter mentioned her blog, and I liked it so much that I had to link to it here:Wellness Rounds.I'm a huge advocate for looking after your personal health, both physical, mental and every other aspect of your life, so this is just the kind of thing I am passionate about, and it would do you some good to have a read, too. I know that it is drummed into us all of the time - doctors and medical students don't take enough care of our own health. This is bad for us, and if we end up unhealthy as a result of lifestyle choices, our patients are less likely to believe our advice when we counsel them to change their ways. Plus, we end up miserable and ill, and nobody really wants to end up an unhappy and sick, particularly if your entire day is spent looking after people suffering the... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=4459982 Thu, 10 Feb 2011 10:55:00 +0100 4459982 http://www.medworm.com/index.php?rid=4450311&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2011%2F02%2Fthings-i-have-learned-during-internship.html You can survive a whole busy evening shift on nothing but adrenaline, two biscuits from the ward kitchen and a bottle of water. But you don't want to do this, and it is awful. (Source: The Girl with the Blue Steth) The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=4450311 Tue, 08 Feb 2011 20:51:00 +0100 4450311 http://www.medworm.com/index.php?rid=4077284&cid=t_122957_101_f&fid=38969&url=http%3A%2F%2Ftheemtspot.com%2F2010%2F10%2F15%2Fskill-acquisition-and-protocols%2F Part one of a two part series. (Part two is here.) If you’ve ever grown plants in pots you know that selecting the right size pot for the plant is essential. Put a plant in a pot that’s too large for it and the new life will struggle to find water and nutrients. Place the same plant in a pot that’s too small and it will struggle to find space to grow. Such is the nature of growing things. It works the same way with you and your skills and your protocols. Your relationship with your protocols is going to change as your knowledge and skill grow. It’s going to happen. This isn’t my opinion. It’s called the Dreyfus model of skill acquisition. And when you understand how it relates to you and your medical skills, you’re bound to have one of those ah-... The EMT Spot blogs http://www.medworm.com/rss/comments.php?id=4077284 Fri, 15 Oct 2010 17:18:05 +0100 4077284 http://www.medworm.com/index.php?rid=4074108&cid=t_122957_101_f&fid=38969&url=http%3A%2F%2Ftheemtspot.com%2F2010%2F10%2F15%2Fskill-acquisition-and-protocols%2F If you’ve ever grown plants in pots you know that selecting the right size pot for the plant is essential. Put a plant in a pot that’s too large for it and the new life will struggle to find water and nutrients. Place the same plant in a pot that’s too small and it will struggle to find space to grow. Such is the nature of growing things. It works the same way with you and your skills and your protocols. Your relationship with your protocols is going to change as your knowledge and skill grow. It’s going to happen. This isn’t my opinion. It’s called the Dreyfus model of skill acquisition. And when you understand how it relates to you and your medical skills, you’re bound to have one of those ah-ha moments. Here’s how it works. Stuart and ... The EMT Spot blogs http://www.medworm.com/rss/comments.php?id=4074108 Fri, 15 Oct 2010 17:18:05 +0100 4074108 http://www.medworm.com/index.php?rid=3794791&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2010%2F07%2Fand-good-news.html I got my first preference for internship! I'm so relieved. And a little scared. I think it will all become more real when the paperwork starts to arrive. (Source: The Girl with the Blue Steth) The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=3794791 Mon, 19 Jul 2010 02:41:00 +0100 3794791 http://www.medworm.com/index.php?rid=3794793&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2010%2F07%2Fexams-again.html We have our exams this week for O&G. They consist of a long T/F paper, and two OSCEs where we are given a fake patient (who can be male and is also the examiner and an O&G physician to boot!) in a structured assessment situation.I'm mildly nervous, but much less than I would have been a year ago. We have been through so many exams in the past few years that it seems so mundane and normal. The thing that is starting to weigh on my mind is internship. I have two lots of rotation exams (including this one), one elective rotation, one MSAT at the end of it all, and then I am technically a (junior) doctor. In studying for these exams, I keep seeing myself actually being in these situations in a year or so. This is helpful for study, as it really makes it stick, but on the flip-side it i... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=3794793 Mon, 12 Jul 2010 04:19:00 +0100 3794793 http://www.medworm.com/index.php?rid=3794794&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2010%2F07%2Fone-week-and-one-day-to-go.html In one week and one day we get our first offers for internship. It is a very exciting time.It has been very interesting that I have made it this far, mainly because I have been focusing so much on taking things one day at a time.I'm trying to work out where the following years may take me, but it isn't easy, particularly as some information is hard to come by. I don't feel like I can call people and ask just yet, as I'm still only a medical student, and email responses are either slow or don't happen. That said, I have received a couple of very helpful responses.Fun times are ahead. (Source: The Girl with the Blue Steth) The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=3794794 Sun, 11 Jul 2010 06:05:00 +0100 3794794 http://www.medworm.com/index.php?rid=3794796&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2010%2F06%2Fnow-to-wait.html For three and a half weeks until our provisional offers come out.At least now I know my odds. It isn't a shoe-in, but it isn't the worst, either. Fortunately I also have a very unpopular hospital within driving distance of my home as my second preference. I don't quite understand why it is so unpopular, as I have heard good things from people who have been interns there, but I can imagine. It isn't a big centre with a load of support. Their interns work hard and learn a lot. I guess it is in a poor area that is too far to drive from most areas in the big city, so they would have to move closer to an area that they don't like. (I would deal with the long drive, I think. I live on that side of the city.)One of the problems with our current system is that the government panicked at the doctor... The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=3794796 Tue, 22 Jun 2010 23:08:00 +0100 3794796 http://www.medworm.com/index.php?rid=3794797&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2010%2F06%2Fmaster-procrastinator.html Our ballot closes very soon.Clearly (from the blog design change) I am procrastinating. Perhaps I need to pull my finger out and do something that would distract me a little better - like, perhaps, studying? :P (Source: The Girl with the Blue Steth) The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=3794797 Mon, 21 Jun 2010 11:34:00 +0100 3794797 http://www.medworm.com/index.php?rid=3794800&cid=t_122957_93_f&fid=34787&url=http%3A%2F%2Fthegirlwiththebluesteth.blogspot.com%2F2010%2F06%2Fintern-applications-have-started.html I have put my name down in the ballot process.We can watch our results live as the numbers change over the two weeks, keeping an eye on how full our preferred hospital is, and changing preferences if we need or want to.This means that people tend to shift their preferences if certain hospitals become over-subscribed to maximise their chances at staying in the big smoke. It also means that less people need to be balloted after the date for change of preference closes, because most hospitals don't end up being massively oversubscribed.Fingers crossed! (Source: The Girl with the Blue Steth) The Girl with the Blue Steth blogs http://www.medworm.com/rss/comments.php?id=3794800 Wed, 09 Jun 2010 04:38:00 +0100 3794800 http://www.medworm.com/index.php?rid=3526713&cid=t_122957_87_f&fid=34935&url=http%3A%2F%2Fmedicine.com.my%2Fwp%2F%3Fp%3D8534 Spotted this Youtube video of interviews with Malaysian housemen from the Malaysian Medical Resources Video: Housemanship in Malaysia (Source: Malaysian Medical Resources) Malaysian Medical Resources blogs http://www.medworm.com/rss/comments.php?id=3526713 Sun, 02 May 2010 23:00:00 +0100 3526713 http://www.medworm.com/index.php?rid=3456719&cid=t_122957_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2010%2F04%2F09%2Flook-whos-depressed-now-interns%2F As though medical school wasn’t difficult enough, now new research suggests that internship is even more difficult. In a study of 740 medical students who were on internship, researchers (Sen et al., 2010) found that nearly 4 percent of the students met the criteria for depression before their internship started. That number jumped to over 25 percent of students when the researchers measured their depression level at four points over the course of the internship year. That’s right — 1 in 4 medical students on internship suffer from serious, clinical depression. Most of the students who met criteria for depression were classified as moderately depressed. That’s in-between mild and severe depression, and in most people, means their daily functioning is significantly ... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=3456719 Fri, 09 Apr 2010 20:38:54 +0100 3456719 http://www.medworm.com/index.php?rid=3227721&cid=t_122957_87_f&fid=36438&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FCato-at-liberty%2F%7E3%2FR7t5gTxN4C0%2F By David BoazAfter 33 years in business, and 33 years of Cato interns, we’re finally getting around to creating an intern alumni newsletter — and an intern reunion this May. So if you were ever an intern for Cato, and you’re not sure Director of Student Programs Joey Coon knows where you are, please let him know. And if you’re still in touch with other fellow interns, please tell them about our plans. If you’d like to be on the alumni newsletter list, and/or get an invitation to the reunion, please contact Joey at jcoon@cato.org and give him your email address and the year/semester you interned at Cato. Throw in your mailing address if you like. And by the way, if you valued your internship at Cato and the work that Cato continues to do, and you’re now a... Cato-at-liberty blogs http://www.medworm.com/rss/comments.php?id=3227721 Mon, 01 Feb 2010 16:32:28 +0100 3227721 http://www.medworm.com/index.php?rid=2660739&cid=t_122957_93_f&fid=35707&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FHemodynamics%2F%7E3%2FJVPf4jBdRds%2Fnight-float.html Our department chair decided at some point that the people on night float shifts--interns who cover the medicine patients overnight, and residents who admit new patients coming in after the regular teams have stopped admitting--should have a teaching session. And so we met this morning, all the night float residents and interns. I've been doing a pinch hitter sort of job, in which I do overnight medicine consults and also support the night float interns; next week I'll be doing admissions. The relationship among all of these people is an odd one. Except for me (because I spend a reasonable amount of time checking in with my early-in-the-year interns and backing them up in various medical crises), we are mostly working alone. But we see each other through the night, crossing paths in the ha... hemodynamics blogs http://www.medworm.com/rss/comments.php?id=2660739 Sat, 01 Aug 2009 06:35:00 +0100 2660739 http://www.medworm.com/index.php?rid=2593100&cid=t_122957_93_f&fid=35707&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FHemodynamics%2F%7E3%2Fh3pZIqvA1ac%2Fbecoming-fat-man.html Sleep-deprived and worried for my interns, I start spouting half-true or all-wrong or kind of right aphorisms as if I was aspiring to be the new Fat Man:"All patients lie. All patients are crazy. And it is our job to love them anyway." (Said to an intern who is tempted to believe everything his patients tell him, to his patients' potential detriment.)A pair of nurses, overhearing this, do a double take and tighten up as they hear me start this, then visibly relax as I finish. One says, "You saved yourself with the last part there." I try to save myself a bit more: "Well, we all lie sometimes, even when we don't realize it, and we're all a little bit crazy, right?" Still, I thought, Am I really the resident who blurts out cheap half-truths as if they were wisdom?It is an inevitable temptati... hemodynamics blogs http://www.medworm.com/rss/comments.php?id=2593100 Sat, 11 Jul 2009 18:15:00 +0100 2593100 http://www.medworm.com/index.php?rid=2591459&cid=t_122957_93_f&fid=35707&url=http%3A%2F%2Ffeedproxy.google.com%2F%7Er%2FHemodynamics%2F%7E3%2FJ7sJBMVdkUk%2F100-true-dialogue-from-wards.html The attending, the senior resident, and the intern are sitting in the work area, discussing a patient. The senior resident, a bespectacled and bearded graduate of Harvard Medical School, is cautioning the intern on jumping to conclusions:"I understand that you're taking the evidence and trying to see if it matches your theory. But actually, you want to do the opposite. You don't want to try to prove yourself right. In the philosophy of science, Karl Popper wrote about 'falsification'--the idea that you take your hypothesis and try to prove it wrong, until, failing to prove it wrong, you decide that it's the best theory for now."The intern: "OK, yeah, I see your point."The attending: "Karl Popper, huh? You've read Karl Popper?"The resident: "No. But I've read about Karl Popper on Wikipedia.... hemodynamics blogs http://www.medworm.com/rss/comments.php?id=2591459 Sat, 11 Jul 2009 02:16:00 +0100 2591459 http://www.medworm.com/index.php?rid=2241712&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2009%2F03%2F05%2Fflashback-2%2F I’m making my way through Cameron’s Current Surgical Therapy, specifically the vascular section, since this is the kind of problem I am most worried about handling alone at night. For one thing, I have a terrible knack for imagining that I feel pedal pulses when there aren’t any, so I always have to make myself get the doppler and check (if the pulse is palpable, it necessarily ought to be audible with doppler; although sometimes, finding the doppler in the depths of the nurses’ station, or on another floor entirely, is almost more challenging than finding the pulses). For another thing, there are so many possible ways to treat vascular problems nowadays, and I feel inadequately versed in all the options, and which ones are appropriate in the middle of the night, an... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2241712 Thu, 05 Mar 2009 20:34:47 +0100 2241712 http://www.medworm.com/index.php?rid=2075523&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F12%2F31%2Ftaboo%2F One of the attendings the other day was trying to debunk some of the superstitions of medicine, particularly the one which warns against saying “quiet” about the ER or the OR, if you want it to stay that way. This myth can be almost paralyzing at times, since all of the nurses and a good many of the doctors subscribe to it. Sometimes at night I find myself running down the thought exercise, ‘try not to think of a pink elephant for a whole minute,’ in other words, don’t consider how much you’re enjoying the night being quiet, because if you think about it being quiet, it’s as bad as saying it. The attending, as I said, was mocking this superstition. Very well for him, but there’s another piece of magic which is real, even if the taboo on &#822... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=2075523 Wed, 31 Dec 2008 21:56:23 +0100 2075523 http://www.medworm.com/index.php?rid=1902365&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F10%2F23%2Fattendance-records%2F 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://www.medworm.com/index.php?rid=1754656&cid=t_122957_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2008%2F09%2F02%2Freflections-at-13%2F We are in the midst of our 13th year on the Web and our 16th year online. And while 13 years on the Web seems old, it still seems like yesterday when I began publishing Psych Central. Thirteen years ago, I was starting my internship year in Poughkeepsie, New York, working in the local community mental health center. It was a great time for me, as I looked forward to moving back up north after four years in South Florida. I met some great people on internship, including my fellow interns (you know who you are!), most of whom went on to successful practices in psychotherapy and such. But this was also the year I came to the realization that as much as I enjoyed doing psychotherapy, it was not the path I was meant for. I’m a great listener, but I’m not as empathetic as I shoul... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=1754656 Tue, 02 Sep 2008 23:35:16 +0100 1754656 http://www.medworm.com/index.php?rid=1631844&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F16%2Fretrospect%2F Last year for the first few months my heart rate shot up to about 140 every time the code pager went off. I learned to do femoral lines in the middle of a code, with no pulse, and the patient bouncing around so much that you couldn’t have found the pulse anyway if it had existed. I had no idea how my juniors managed to remain so calm about a pulseless patient and me waving long needles in the air in the middle of the chaos. Now I’m smiling coolly when the new interns look at their code pagers and express some concern about being responsible for putting in lines, when they’ve never done any yet. Don’t worry, I tell them, you’ll learn just fine; I’ll come and watch. Because I know, if they don’t get it, I will. Sooner or later. Me panicking won&#8217... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1631844 Thu, 17 Jul 2008 00:22:35 +0100 1631844 http://www.medworm.com/index.php?rid=1594128&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F07%2Fwhat-not-to-say-on-rounds%2F There’s really not much to say about this academic year, so far. I haven’t gotten to do really any more surgeries. The chief keeps intending to let me, but then the case turns out so wildly complicated that I can’t honestly say it would be a good idea to let me in, so I can’t complain. I don’t know any more now than I did a week ago, it’s just that the amazingly naive intern at my heels makes me look relatively well-informed, and even almost sophisticated. (One thing I learned the painful way: you do not have to tell the attending every single detail of what happened in the last 24 hours, such as, we wanted to check such and such a lab, but it took forever to draw, and then the lab lost the blood sample, so it was twelve hours after admission before we d... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1594128 Tue, 08 Jul 2008 00:35:42 +0100 1594128 http://www.medworm.com/index.php?rid=1561527&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F07%2F01%2Fnew-faces%2F July 1 - a very good day for staying out of the hospital. Actually I don’t know why everyone repeats that, because nothing very bad happened. The attendings and seniors were practically breathing down the juniors’ and interns’ necks, and there was not much opportunity for error. My service was relatively light, so I wasn’t called on to do anything out of the ordinary, which was just fine with me. I mainly babysat the intern all day. At first it was fun, because I wanted to help them and smooth the transition. By the end of the day, though, I was rather annoyed, and am trying to figure out whether all the interns are that infuriating, or mine was special. I’m going to try to keep giving them the benefit of the doubt for at least another week, and try to remembe... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1561527 Wed, 02 Jul 2008 00:06:26 +0100 1561527 http://www.medworm.com/index.php?rid=1554702&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F29%2Fimitation-is-flattery%2F One more day of internship left. It’s a little hard to believe. I’m making a couple of notes for myself about what I most admired in the junior residents I worked with over the last year, because I know that within a month, if not less, I’ll have completely forgotten what it was like to be an intern. (The same way that I’ve forgotten what it was like to be a medical student. For the med students out there wondering, “How can the residents treat us like this? Don’t they remember what it was like?” the answer is, no, we don’t remember, because things change so fast in just a few years. I remember third year of medical school about as much as I remember college, unless I concentrate. Even my own blog from back then seems foreign. I’m a di... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1554702 Mon, 30 Jun 2008 00:58:13 +0100 1554702 http://www.medworm.com/index.php?rid=1554703&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F28%2Fbackwards-and-forwards%2F Now that we’re getting down to the wire, I’m having the same butterflies I did last year at this time. The butterflies are riding a rollercoaster - first excitement at moving on then, and then fear at the prospect of having even more responsibility than I have now. There’s also the vertigo-inducing exercise of turning around, as it were, and remembering how the second-year residents looked to me when I started last year. I revered them nearly as much as I revered the chiefs - and them I nearly worshipped (which is just as well, because the executive chief is the direct manifestation of the program’s control over your life). And then to turn back, and realize how lost I’m going to feel, and the interns are going to be looking at me with - hopefully not reverenc... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1554703 Sun, 29 Jun 2008 00:28:22 +0100 1554703 http://www.medworm.com/index.php?rid=1552253&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F27%2Flessons-learned%2F Correction to the last post: I guess there was one attending in the group whom I didn’t totally antagonize. If we were playing a game of “pick one attending you’d like to be on the good side of,” I’d have chosen him, since he’s powerful, and has a very sharp tongue when he’s displeased. Actually, I don’t know how, I seem to have impressed him well enough that as I spent the morning stumbling through rounds, he remarked a couple of times: “I know Dr. Alice is a very good resident. In fact, she’s one of the best we’ve had all year. I don’t know what’s happened to her this morning, but I guess we can excuse her for one day.” Mmm, thanks; I suppose there’s a limit to how many days I can work straight, no ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1552253 Sat, 28 Jun 2008 00:24:43 +0100 1552253 http://www.medworm.com/index.php?rid=1552254&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F26%2Fa-little-backwards%2F I’ve been reading some of the never-ending controversy in the medical blogosphere about the 80-hr week (some are talking about 57hrs as though it’s a definite development; that had just better not be true). I thought I’d add a slightly different perspective: Today I worked about 14 hrs - came in an hour earlier than I was supposed to, and left an hour later than I was supposed to; not bad for a surgery intern. At the end, I walked away from a sick patient who will likely to go the OR tonight, I’d guess around midnight. When I left, he wasn’t acutely decompensating; his pressure had stabilized and he didn’t need to be intubated, yet, although there were more lines being put in. I had admitted him; he was one of the traumas that came in all together, and... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1552254 Fri, 27 Jun 2008 01:21:52 +0100 1552254 http://www.medworm.com/index.php?rid=1552255&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F26%2Fa-different-world%2F Probably the person that I feel most sorry for, over the last month, is the neurosurgery intern. At my hospital, the neurosurgery intern belongs to general surgery for eleven months, and then in June, the mother ship comes for him and he gets swallowed up by the neurosurgery program (which, since it has twice as many attendings as residents, and all very busy, does indeed literally swallow up the residents). He’s doing q2 or q3 call now, and can be found in the hospital, running between the ICU and the ER, at basically any time of day or night, any day of the week. He will be doing this for at least the next year, as the junior-est of the neurosurgery residents gets worked to death by the attendings, and by the rest of the residents who regard it as their turn to stop taking q2 call.... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1552255 Fri, 27 Jun 2008 00:31:26 +0100 1552255 http://www.medworm.com/index.php?rid=1552256&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F26%2Fbetter-and-worse%2F Thanks everyone for the encouraging comments. I think things are getting better overall; I can handle four more days. Today continued to be splendid. My efforts to discharge patients to the floor succeeded mainly in disgruntling the floor staff, and led to one of my . . . episodes . . . with an attending today. All the hard work didn’t do me much good, because we just admitted more patients through the ER as fast as I could discharge them to the floor. Yes, I seem to have ticked off every single attending in this group - three of them today. That has to be some kind of record for the worst resident performance ever, wouldn’t you think? With one of them I really did something wrong - forgot something that a resident four days away from being a responsible junior resident shouldn... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1552256 Fri, 27 Jun 2008 00:24:47 +0100 1552256 http://www.medworm.com/index.php?rid=1544326&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F24%2Fugly-inside%2F I really had better not talk. I wrote a very bitter post about how angry I am at the hospital administration, but it was too nasty too publish. I’m so stressed out, between the administration’s actions, and just the ICU and trauma craziness, I’m making myself sick, which isn’t smart, because there’s absolutely no one to cover for me, so I’m not about to try to find out what happens if a resident takes a sick day (although I’m tempted to try it, just to pay some people back). Today wasn’t so awful, I’m learning to just not talk to the attendings and then things go smoother. Tomorrow, I think the seniors have arranged things so that I get to cover the entire trauma ICU, and go to all the trauma alerts in the ER, by myself. I’m so t... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1544326 Wed, 25 Jun 2008 01:05:43 +0100 1544326 http://www.medworm.com/index.php?rid=1538510&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F22%2Fwhirlwind%2F I was dreading rounds today, but something lit a fire under the attending (perhaps the arrival of three traumas before 9am), and he tore through rounds in what was probably record time for him. We just barely made it, too, because right around 1pm the traumas started pouring in. I don’t think we got out of the ER for more than 15 minutes all afternoon (and watching the pager, they’re still coming in; it’s starting to rain now, instead of the brilliant sunshine, so maybe people will get smart and go inside). One trauma after another, and usually two or three at once. In one sense, I enjoyed it, because I would much rather be dealing with a whirl of excitement in the trauma bay and the CT scanner rather than dragging my feet through the unit (although after about half an ho... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1538510 Mon, 23 Jun 2008 00:21:15 +0100 1538510 http://www.medworm.com/index.php?rid=1536793&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F21%2Frunning-at-a-snails-pace%2F Okay, now I’m annoyed. I left the hospital at 8:30pm, not because the patients were so sick or I was so busy (although they were and I was), but because the attending took twelve hours to round. I’m telling myself that I’m not upset just by the time of day, but because the time was wasted. I’ve stayed till 8 and 9pm before, and not been too unhappy, because I was doing procedures, or taking care of a patient who seemed too unstable to sign out. But twelve hours rounding? This is the attending who can be found in the hospital most nights of the week, regardless of the call schedule. This morning we came for sign-in, and he told us about something he’d taken care of overnight. “But you weren’t on call last night. You’re on call tonight.” ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1536793 Sun, 22 Jun 2008 01:20:37 +0100 1536793 http://www.medworm.com/index.php?rid=1536063&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F20%2Fnot-a-success%2F Not a great day at all. We got snowed overnight (and how exactly do you double a trauma unit’s census on a Thursday night? what happened to the concept of partying on weekends?) (although, of course, it’s the elderly people falling and breaking things that really does us in), and I came in expecting a short list, to find a combination of crashing patients brought up from the ER, and patients in extremis brought down from the floor, such that I didn’t manage to do any kind of decent pre-rounds before attending rounds. I’d seen the patients, written down the vital signs, and was staking my life on my belief in the nurses’ statements that “yes, everything’s ok, no major problems.” They were correct, but I hate rounding on the fly. I know I&#8217... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1536063 Sat, 21 Jun 2008 00:18:48 +0100 1536063 http://www.medworm.com/index.php?rid=1532073&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F19%2Fplanning-ahead-3%2F Two weeks till the new interns get here. Actually they’ll be here earlier, for orientation, but two weeks till they start working. Last July 1 seems like a million years ago, a different lifetime. The time has flown since then; I don’t feel like it’s been as long as a year, but somehow more than a year has happened in between. I really am a doctor now, and the more I think about it, the more I think I do know enough to take care of the interns and their patients properly. It’s my new patients, four ICUs full of them, that I’m more worried about. I have a feeling I’m going to be on call 4th of July weekend; perhaps it would be just as well to jump right in and get it over with. Most of our interns for the next year came through here as medical students, s... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1532073 Thu, 19 Jun 2008 15:43:14 +0100 1532073 http://www.medworm.com/index.php?rid=1526174&cid=t_122957_88_f&fid=34857&url=http%3A%2F%2Fscalpelorsword.blogspot.com%2F2007%2F07%2Fwork-hard-succeed.html This column was originally posted in July of 2007.For the benefit of the new interns, I'll now present my own perspective on internship.I like to think that my own internship was more like this guy's than the type being advocated amongst some of my fellow medbloggers these days. I was a mediocre medical student, smack dab in the middle of the bell curve, but I ultimately became the best intern in my large program. "How could that be?" you might ask. Simple...I worked harder than anyone else. If you finished medical school at the top of your class, you are ahead of the game and you probably are already anticipating your cushy Dermatology lifestyle. Otherwise, if you want to be successful, you are going to have to turn it up a notch.Here's a newsflash for you....the most competitive post-res... Scalpel or Sword? blogs http://www.medworm.com/rss/comments.php?id=1526174 Tue, 17 Jun 2008 12:01:00 +0100 1526174 http://www.medworm.com/index.php?rid=1522675&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F16%2Flost-in-the-maze%2F My list of patients has steadied down to a group of long-term ICU inhabitants. Good, because I don’t have to figure out four or five entirely new patients every morning. Bad, because since they stay so long, they get very complicated. Rounds are always full of pitholes from the attending: “A new arrhythmia, eh? Let’s consult cardiology. Oh, we already did consult cardiology? What did they say?” “Um, actually [flipping wildly through the chart and the computer] we consulted them five weeks ago with a questionable MI, which they said wasn’t significant, and they seem to have signed off a while ago. . . I can’t see any notes in recent memory here.” “Ok. . . this drain here, where does it go?” “Sir, I really couldn’t tell ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1522675 Tue, 17 Jun 2008 01:44:49 +0100 1522675 http://www.medworm.com/index.php?rid=1522676&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F15%2Fscalpels-are-sharp-for-a-reason%2F One of my patients this month has been an amazing teacher. He hasn’t said a word yet, and I might be off the service before we get him off the vent and onto a trach that he can talk with, but I’ve already learned a lot from him. He was in a car accident, and came in with some broken ribs. Not bad, right? So no one could understand why his vital signs steadily dropped in the trauma bay. He looked good initially, but right when the team thought they had him figured out and ready for admission upstairs, he took a turn for the worse. The on-call attending stayed four hours late, intubating him, scanning him again, starting him on pressors, fighting with the vent settings, trying to save his life, and completely lost as to what the problem was. He got to the trauma unit eventually, ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1522676 Mon, 16 Jun 2008 01:57:44 +0100 1522676 http://www.medworm.com/index.php?rid=1517020&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F12%2Ffull-circle%2F The only resident I met in medical school who made me seriously reconsider my interest in surgery was rotating on trauma. In fact, he seemed to have stopped rotating, and have come to rest in the trauma unit. Between the summer transition, and the vagaries of scheduling, he was spending three or four months consecutively on trauma, either days or nights. He was not happy at all. In fact, he was downright bitter. I think his wife was giving him grief about never seeing him, but he also hated the trauma unit in itself. “Do anything else at all, just don’t do surgery.” “I would never do this again.” “If there’s anything else you could be happy doing, don’t do surgery.” I remember watching him walk around the unit, running from one disaster... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1517020 Thu, 12 Jun 2008 23:44:05 +0100 1517020 http://www.medworm.com/index.php?rid=1509564&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F11%2Fplease-get-me-out-of-here%2F Again, so annoyed and frustrated I can’t talk. What’s especially bad is that the rest of the trauma ICU knows it: the nurses are commiserating with me (which I shouldn’t let it get to that point), the rest of the residents are teasing me, and so far the attending thinks it’s funny that I’m nearly biting my nails off, and literally pacing the halls in frustration as he spends half an hour rounding on each patient. I simply cannot stand still and think about one thing for that long. It’s a different attending these couple of days. He’s a nice enough person, but he’s so slooowww. . . It feels like nails grating on a chalkboard. And I feel guilty, because he’s being thorough, and an extremely good doctor - but I wish he would delegate some ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1509564 Wed, 11 Jun 2008 23:42:40 +0100 1509564 http://www.medworm.com/index.php?rid=1509565&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F10%2Fgrin-and-bear-it-4%2F I’m so frustrated and annoyed, I’m not going to write anything. Some of the attendings are driving me crazy, and so are some of the seniors. The patients themselves are not bad, especially since I seem to have randomly picked up all the people who are chronically on the vent. I’m familiar with them now, and am getting used to the slow dance of changing one vent setting (oxygen flow, pressure, volume, rate) at a time, and waiting to see if they’ll gain the strength to start breathing on their own again, while keeping a careful eye out for pneumonias which will knock them back by at least a week. Now if some people would teach, instead of making criticisms all the time, and about things that I didn’t actually do, or had a good reason for doing but they won&#8217... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1509565 Wed, 11 Jun 2008 00:13:11 +0100 1509565 http://www.medworm.com/index.php?rid=1509566&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F09%2Fanother-first-2%2F One of my patients died today, the first time that I was actually around for such an event. He was kind of a hopeless situation from the time he came in a few days ago, but we gave it our best shot. His family knew the prognosis was bad, and today when some tests confirmed that he had basically no brain function left, they agreed to withdraw care. I talked to them from the beginning, putting out the likelihood that he wouldn’t recover and that a decision would have to be made. Today I was trying to hide, letting subspecialists talk to them, but of course it wasn’t that easy. “Alice, we finished our discussion, now they’re asking to talk to you.” The family seemed like great people, a strong family. They had a spokesperson who asked questions, and then announce... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1509566 Tue, 10 Jun 2008 00:04:02 +0100 1509566 http://www.medworm.com/index.php?rid=1502937&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F08%2Fah-gratitude%2F The weekend wasn’t quite as bad as expected. Enough sick patients and enough traumas can get even the slowest of attendings to start moving, and I like this attending better at midnight, arguing with helicopter command about the tenth ridiculous trauma alert of the evening and struggling to keep the seven car accidents and six motorcycle accidents straight, than during morning rounds. On the other hand, I had trouble with lines again. I got some good a-lines in, hurrying before rounds started. (I’m afraid I drive the ICU nurses crazy. I show up right after shift change and insist on putting in lines or changing wound dressings, right then. My only excuse is if I don’t do it then, it won’t happen. I didn’t stop moving for 30 hours this weekend, and lots of sma... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1502937 Mon, 09 Jun 2008 00:47:45 +0100 1502937 http://www.medworm.com/index.php?rid=1500554&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F06%2Fdeluge%2F It’s a routine day on the trauma service: one attending operating as fast as the rooms can be turned around (it somehow takes longer when your patients are from the ICU, because anesthesia takes their sweet time about going to get the patient, and it takes forever to package all the lines, monitors, and vent equipment, and then repeat for the trip back, plus wild stops to check and see why the ekg readings have gone skywire, and whether that O2 saturation reading is accurate or not, and did we hook the bag up to oxygen, or not?), and the other attending operating even more busily on unscheduled eruptions: come to find out, that spleen is going bad, after 24 hours of observation, time for an exploratory laparotomy; oh, undiagnosed viscus injury, five days after trauma, let’s cal... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1500554 Sat, 07 Jun 2008 01:35:11 +0100 1500554 http://www.medworm.com/index.php?rid=1497957&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F05%2Fsharp-objects%2F I am, again, pleased with myself. We have a patient who’s septic from quite mysterious reasons (well, I suppose positive blood cultures ought to explain why he’s septic, except you still have to figure out how it got in his blood, and why he’s growing, as the nurse said, “everything but the kitchen sink” in there - gram positive cocci, gram negative rods; gram positive rods, gram negative diplocci; and who knows which of those to believe). (Not to mention what he’s doing on the trauma service; but that’s another perennial issue, how we end up with general surgery, orthopedic surgery, neurosurgery, and downright medical ICU patients on our service. Educational, but frustrating.) Anyway, the a-line was going bad, and we needed another one. I spent ne... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1497957 Fri, 06 Jun 2008 01:07:48 +0100 1497957 http://www.medworm.com/index.php?rid=1494743&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F04%2Fchanging-times%2F I used not to drink coffee at all. I got all the way through college and medical school, and six or seven months into internship, without drinking coffee. I didn’t like the idea of depending on any chemical to be awake, and I knew that a coffee habit could become quite expensive. I gave up, of course. The hospital has a very nice coffee shop, and our meal tickets work there. That means trading a real meal later on for coffee in the morning, but if you have time for coffee, and no guarantee of having time for a meal, that doesn’t matter so much. I think it was the second month of night float when I really stopped even trying not to drink coffee. If you put enough milk and sugar in, it doesn’t taste bad. It feels like a grown-up thing to do, and it actually does help you ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1494743 Wed, 04 Jun 2008 17:52:54 +0100 1494743 http://www.medworm.com/index.php?rid=1492474&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F03%2Fpractice-run%2F There was one point the other day where all the senior residents associated with the trauma team had disappeared - some into the OR, and others apparently into thin air. The attending had also dematerialized out of the middle of rounds. Probably to the OR, but he never said where he was going, and we were left in limbo, wondering where exactly everyone had gone. Then the trauma pagers went off. (You always know it’s a trauma page, because in the trauma unit it’s like an orchestra of pagers has started - all kinds of beeps and trills and cheeps and buzzes, in complete unison. The charge nurses and respiratory therapists and other random people get these pages, as well as us.) “50yo male pedestrian struck by car, thrown 20feet, chest pain.” You can never tell from the... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1492474 Wed, 04 Jun 2008 00:25:59 +0100 1492474 http://www.medworm.com/index.php?rid=1485110&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F06%2F01%2Finsanity-2%2F Trauma is crazy. I’m not going to tell you how long I spent in the hospital today, but let’s just say that for a day I wasn’t supposed to be on call, I saw an awful lot of the night float people. Prolonged ICU rounds has got to be the definition of torture for surgery residents. That explains why we all tend to have the feeling that there is something deeply wrong with the attendings, who trained as surgeons, and are still surgeons enough to dive comfortably into trauma bellies and chests, but nevertheless choose to spend their lives rounding on trauma patients. The day was a long stretch of boredom - staring at my hands while the other residents presented their patients, or staring at my note sheet while the attending slowly wrote his note based on what I had told him - ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1485110 Mon, 02 Jun 2008 01:30:58 +0100 1485110 http://www.medworm.com/index.php?rid=1482170&cid=t_122957_93_f&fid=35707&url=http%3A%2F%2Fhemodynamics.blogspot.com%2F2008%2F05%2Fspiritual-purpose-of-intern.html video: a science teacher demonstrating that potassium in water is dangerous--and to think I prescribe this stuff every day! Interns working on our floor keep getting pages that go something like this:"Please address chloride levels on your patients. 43770"Various interns have done various things in response to these pages, including calling the number which is never answered. My own response was to think, "What the hell?" The page was like an extreme version of the very common pages we get from nurses: "K is 3.5 on Mr D in Farr 225, do you want to replete" or better yet, "Smith's Mg is 1.8, please put in order to replete". Some time ago some people showed that after heart attacks, people had fewer ventricular arrythmias when their potassium (periodic table of elements label = K) was above ... hemodynamics blogs http://www.medworm.com/rss/comments.php?id=1482170 Sun, 01 Jun 2008 03:25:00 +0100 1482170 http://www.medworm.com/index.php?rid=1482171&cid=t_122957_93_f&fid=35707&url=http%3A%2F%2Fhemodynamics.blogspot.com%2F2008%2F05%2Fat-hospital-computers-anonymous-toilers.html Statcounter.com allows me to track what recent search terms people have used to find this site. A few people are clearly looking for this site specifically; most stumble on it with Google searches that lead them here--maybe the same way you ended up here. Here's my favorite Google search phrase that led someone here, from a hospital-based server far far away:"i'm a medical resident and i feel stupid"This phrase put into Google's search box led the searcher to this blog. And all I can say is, brother or sister doctor-in-training, I feel you. Keep searching. (Source: hemodynamics) hemodynamics blogs http://www.medworm.com/rss/comments.php?id=1482171 Sun, 01 Jun 2008 03:12:00 +0100 1482171 http://www.medworm.com/index.php?rid=1482696&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F31%2Floose-ends%2F I have more stories from vascular, but the best ones are so unique, they’re almost worthy of being published case reports, so I don’t want to tell them for a while, for hipaa-type reasons. In general, I’m going to miss this month. Usually it’s a service the residents love to hate, because it’s so insanely busy, and the patients, though wonderful people, have a propensity to spiral at any moment. You have to have a much higher level of suspicion for all kinds of things, from heart attacks and strokes to UTIs and wound infections. But I had perhaps the best chief of the year, and one of the best junior residents, and the attendings are great. Most vascular attendings are. There’s something about the field that attracts people who like to dissect a problem ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1482696 Sun, 01 Jun 2008 00:28:25 +0100 1482696 http://www.medworm.com/index.php?rid=1481043&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F30%2Fstill-juggling%2F The service slowed down a little today, and I was able to spend some time catching up and taking care of details. Which was good, because every time I went through the floor I found another patient with issues that neither I nor the nurses had recognized before. I’m frustrated with myself, because I ought to be catching this stuff the first time through, but I’m also frustrated with the nurses, because it’s part of their job to tell me about stuff like this. But I’m no good at telling nurses to do something better, so I usually don’t even try to blame them for anything. I just make resolutions to be more attentive. I had one patient out of the blue start telling me I was a great doctor, and could he come to my office when I was done training? I couldn’t ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1481043 Sat, 31 May 2008 00:12:59 +0100 1481043 http://www.medworm.com/index.php?rid=1478386&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F29%2Frushing%2F I have a new diet plan. It’s called: come in to work so early you’re not hungry, start in the OR so early there’s no time for breakfast, operate straight through lunchtime, and spend the end of the day running so hard to catch up that there’s no time to eat, and you get out too late to eat much dinner. Actually it doesn’t work too well, because then I get tired of not eating, and very depressed about peanut butter sandwiches and ramen soup, and I let myself believe that Chinese takeout is healthier because it contains vegetables. The day was crazy. I found myself once again holding a retractor and the suction while blood spouted all over me and the attending (more him than me, which was somehow comforting) and the anesthesiologists started spinning around up t... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1478386 Fri, 30 May 2008 00:51:21 +0100 1478386 http://www.medworm.com/index.php?rid=1470328&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F26%2Fhyper%2F I’m not going to say how many hours I worked in the last four days, in case the ACGME ever finds this blog. Let’s just say neither I, nor the other residents involved in the holiday weekend, plan to let anyone know officially how much time we spent in the hospital. Our program is good to us as a matter of course, and we have no intention of letting the cracks show. I saw half a dozen unique cases; not just zebras, but orynxes and wildebeests - legendary diagnoses that even the attendings who diagnosed them had never seen before. My patients got such continuity of care, it was unbelievable; they started asking if I actually have a house, or just live in the hospital. I got to see cases, the postop course, the complications, the treatment of the complications, the result of that ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1470328 Tue, 27 May 2008 00:07:57 +0100 1470328 http://www.medworm.com/index.php?rid=1468005&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F25%2Fthe-zoo%2F Memorial Day weekend + the first good weather in a few weeks = traumas galore. And if you bring in enough trauma victims, sooner or later you’ll find enough serious injuries to keep the ORs running. Ortho, neuro, general surgery - the attendings were resigned, the residents were fairly cheerful, but the techs and circulators who got called in for backup and more backup when they were trying to sleep were not exactly pleased. In addition to the trauma scene, the black cloud that’s hanging over the surgical services continued to rain. The ER couldn’t tell what had come over us: we spent the day in the ER, admitting like there was no tomorrow. Every time they gave us a name, we took one peak and said, “Yeah, sure, it’s our patient, they’re sick, it’s... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1468005 Sun, 25 May 2008 21:24:31 +0100 1468005 http://www.medworm.com/index.php?rid=1464416&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F22%2Fpurposeful-activity%2F At the beginning of the month, one of the interns told me, “Have fun with vascular. Every day on that service, by 4pm, I wanted to jump off the roof.” I told myself I was determined to keep a better attitude than that, and then made a note to see how long I could keep it up. As you can tell from previous posts, I think it’s not too bad yet (although as an excuse for the other intern, perhaps less busy this month, in my usual white cloud style). Nevertheless, by 4-5pm, I start to cringe whenever anyone talks to me. Things invariably fall apart at this time of day. Postops hit the floor with urinary retention, hypertension, hypotension, tachycardia, bradycardia, lack of pain control, family members who need to be talked to. All of which I enjoy dealing with, but not all at ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1464416 Fri, 23 May 2008 01:08:14 +0100 1464416 http://www.medworm.com/index.php?rid=1461401&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F21%2Fbouncy%2F I seem to be saying this a lot lately, and I hope it’s not getting monotonous, but: I am so happy to be where I am, doing what I am. Every time I walk into through the doors labelled “OR attire required beyond this point,” I am thrilled to be one of the people privileged to walk through and belong there. It’s like a secret kingdom, hidden inside the hospital, which is completely closed to 90% of the doctors and nurses here - and I have the key. I’m walking in a lot, because the last couple days have been full of consults and admissions. Every hour or so, I turn around and there’s another patient showing up; or that’s what it feels like. I spend hours every morning discharging people, and by evening the list is longer than it was to start with. But... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1461401 Thu, 22 May 2008 00:30:52 +0100 1461401 http://www.medworm.com/index.php?rid=1459008&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F20%2Fambushed-by-an-av-fistula%2F I am, with laudable restraint, not going to tell the latest story about an ER mis(sed?)diagnosis. Suffice it to say that even attending surgeons were going out of their way to look at the scans and read the notes and laugh at it. Actually, sadly, I think we’re laughing to distract ourselves from the patient’s truly tragic situation. As the primary service, we can’t avoid dealing with it; and it’s not pretty. But I’m encouraged not to join in the scoffing by trying to figure out what I, personally, would have done differently if I’d seen the patient at the beginning; and I’m not sure I can think of anything, other than a wild shotgun approach to every elderly patient with a vague complaint; which is definitely not a good conclusion. It’s easy ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1459008 Wed, 21 May 2008 01:32:09 +0100 1459008 http://www.medworm.com/index.php?rid=1449748&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F17%2Funexpected-2%2F I went by my mailbox the other day to clean out the usual accumulation of useless fliers and advices from the administration (a new administrator; a new policy; a hospital picnic), and was astonished to find a card in the box. It was from a woman whose husband’s hand I had sewn up back in March. It wasn’t the most horrible injury I saw that month, but it was certainly sickening to people, like the man and his wife, who hadn’t seen anything like it before. It had taken me some effort to talk him into letting me take my time and do things carefully. Once I got the anesthetic in it hadn’t been that bad. I think the previous ER where he’d been had tried to do a digital nerve block and failed. I got it right (for the first time ever, to my own surprise; but I didn&... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1449748 Sat, 17 May 2008 14:12:03 +0100 1449748 http://www.medworm.com/index.php?rid=1443128&cid=t_122957_93_f&fid=35707&url=http%3A%2F%2Fhemodynamics.blogspot.com%2F2008%2F05%2Fadvance-by-day-maintain-by-night.html If hospitals finally designed truly rational production processes and became 24 hour enterprises, care might work better and be safer--but where would the romance of the night shift be?I'm quoted today in White Coat Notes, a brief quote in which I say that in the hospital "We maintain by night and advance by day", which might be worth explaining a bit more.The hospital is a constant production process. But it's in transition: it inherits many of the features of its pre-industrial roots. A truly efficient production process never stops, but the hospital slows down considerably at night. I think there would be a lot to be said for a truly 24-hour hospital. But that would require more health care workers, more money to pay people extra to work overnight, and a completely different way of arra... hemodynamics blogs http://www.medworm.com/rss/comments.php?id=1443128 Wed, 14 May 2008 23:14:00 +0100 1443128 http://www.medworm.com/index.php?rid=1433988&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F09%2Fjuggling-badly%2F I can’t decide whether it was a good or bad day. A lady who was supposed to have a major vascular procedure developed a very serious complication early in to the operation. Through a complicated series of events, the attending got the impression that she was better, and went to his office. I came back to check a little later, and found her much worse. (And I didn’t get up the nerve all day to go and chew out the people who were responsible for letting her deteriorate unnoticed; not that noticing would have changed the course of events. I need to grow a spine and some teeth, and they’ll hear about it tomorrow.) By this time the attending was gone, and every single other surgery resident in the hospital was scrubbed in the OR. So I had her to myself all day. It was good, be... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1433988 Sat, 10 May 2008 02:03:34 +0100 1433988 http://www.medworm.com/index.php?rid=1433005&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F08%2Frat-race%2F My service is a mess. Despite me and all the other residents and some mid-level providers scurrying around all day, every night we find ourselves with a crazy list, on which I don’t recognize half the names, don’t know what procedures they had done, why they’re in the hospital, what medications they’re taking, or what we’re supposed to do with them tomorrow. I’m not sure how it happens. Perhaps the habit of sending the intern to do the last cases of the day, which are the small potatoes, at the same time that the ER and the office flood us with new admissions and consults, might have something to do with it. A few months back, when I was covering at night for vascular, I used to be very frustrated with the intern who signed out to me. He’s perhaps ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1433005 Fri, 09 May 2008 00:42:02 +0100 1433005 http://www.medworm.com/index.php?rid=1420657&cid=t_122957_93_f&fid=35707&url=http%3A%2F%2Fhemodynamics.blogspot.com%2F2008%2F05%2Fold-shoes.html Late night in the unit. My resident and I are finishing up an admission and hanging out with the night nurses. They're experienced critical care nurses. Somehow we get to dumb ways that interns behave with nurses. These conversations are common and I think it's because they serve a social function: by telling these stories the nurses are saying, "We know you're not that kind of doctor", and also, "You better not even think about becoming that kind of doctor" and also "If you do become that kind of doctor, you better know we're going to laugh about you and tell stories about you behind your back, including to your colleagues." The doctor end of this conversation is, "I really want to be buddies with the nurses" and "I promise I won't become that kind of doctor." Anyway, the best punchline t... hemodynamics blogs http://www.medworm.com/rss/comments.php?id=1420657 Mon, 05 May 2008 13:13:00 +0100 1420657 http://www.medworm.com/index.php?rid=1419171&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F05%2F03%2Ftwo-months-left%2F I am now on the vascular service, which is probably the busiest surgical service in this hospital (as at most). There are enough attendings operating that I will probably get a few cases a week - of course, the ones no one else wants: ablation of varicose veins, amputations, simple angiography. This service also tends to pick up a lot of pointless consults: our favorites are femoral pseudoaneurysms as a complication of cardiac catheterization (which a priori means that if the patient eventually requires surgery, they’re going to be a very poor cardiac risk), and generally whenever anyone is bleeding. Somehow, to the ER and ICU doctors, bleeding means vascular surgery should be able to help. Sometimes it’s interesting; most of the time, our advice is to hold pressure for a lot l... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1419171 Sun, 04 May 2008 02:43:42 +0100 1419171 http://www.medworm.com/index.php?rid=1405523&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F28%2Fdexterity%2F I am inordinately pleased with myself, and much more optimistic about my future as a surgeon. After the blunders of the last week, something went very right. The chief and I found ourselves elbow-deep in a difficult case, and I was the one with the bovie. (Surprisingly, the junior person is often the one cutting, because the other surgeon needs to have their hands free to see and feel what’s happening and give directions.) The medical student was providing much-needed retraction (you guys have no idea how wonderful it is when you hold the retractors right, and we can really see what we’re doing), so I had both hands free to do surgery with. There was a difficult angle to get across, so for quite a while I found myself guiding a kelly (clamp) with my right hand, and using the bo... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1405523 Mon, 28 Apr 2008 22:47:58 +0100 1405523 http://www.medworm.com/index.php?rid=1403085&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F27%2Ftoo-much-of-a-good-thing%2F I’m convinced I’m a white cloud, and I’d like to know how to change that. “White cloud” is residents’ slang for a person who doesn’t seem to have patients come in, surgeries or codes happen, or patients transfer to the ICU or die on them. I think it really developed more as a corollary to the original phrase, “black cloud,” which is someone who attracts bad luck: when they’re on call, their team picks up more than their fair share of new patients; their patients always go to the OR, or the ICU, or die. Being a white cloud is nice for a while, since it means less work - fewer admissions, transfers, and postop orders to write. But it really adds up to worse education. Getting slammed all day and night with admissions and disasters i... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1403085 Mon, 28 Apr 2008 02:06:24 +0100 1403085 http://www.medworm.com/index.php?rid=1403086&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F27%2Fcoming-soon%2F I think that’s enough about Mormonism and Islam - especially at the same time. As some have suggested, it’s perhaps best not to tackle two giants at once. On the other hand, next time we could include Jehovah’s Witnesses, or maybe the Unitarians. Three times the fun? Thanks to all who commented. In response to many questions lately, I am working on a post or two of advice for surgical interns - a subject I take up with some trepidation because among those who remember her, that phrase instantly brings to mind Barbados Butterfly, a surgical registrar in Australia, who was, until forced by her hospital’s administration to take her blog down, one of the very best medical bloggers; certainly my favorite. She combined a dry sense of humor with a good deal of medical wisd... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1403086 Mon, 28 Apr 2008 00:24:16 +0100 1403086 http://www.medworm.com/index.php?rid=1400778&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F25%2Fblue%2F Ok, it’s still a bad day. As predicted, I got involved in trouble. I don’t think it was my fault; on the other hand, I didn’t do much to stop it. On the third hand, I’m not sure what I could have done differently. On the fourth hand, the senior residents either think I could have done something, or are determined to enjoy teasing me about it; probably the latter. Let’s just say that I was involved in doing a cardinal thing that you’re not supposed to do, because it has bad results; and now I know why, and I will devote a lot of thought to never being in that place again. The chief, bless his heart, stopped the teasing long enough to make a real teaching effort, and went through all the things that someone should have done differently. So that was worthw... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1400778 Sat, 26 Apr 2008 00:59:01 +0100 1400778 http://www.medworm.com/index.php?rid=1397861&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F24%2Fmelancholy%2F It’s a bad day. I discharged my poor fellow with terminal cancer - again. We ended up crying and holding each other’s hands, and it was all I could do not to hug him, because if I had he would never have let go, and I would have dissolved, and it would have been too hard to go on to the next patient. The fact that he’s a little demented and doesn’t remember the details of our conversations doesn’t make it any easier to say goodbye to him. Another patient, a good ways out from a big surgery, had a major setback today. We were all crushed. We thought he was good, he was flying, he was going to be a success, almost ready for discharge - and now this. So utterly disappointing. I keep doing stupid little things; nothing major, I just can’t seem to get the de... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1397861 Fri, 25 Apr 2008 00:27:41 +0100 1397861 http://www.medworm.com/index.php?rid=1395237&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F23%2Fmissing-gene%2F I’ve figured out what my problem is: I don’t have any common sense. There was a patient today, and I just couldn’t get it right. The only good thing about the whole humiliating episode was that I erred on the side of overestimating the patient’s illness, not underestimating it. (Humiliating as in, now anyone in the hospital who had any doubts about my competency/intelligence/character has had them answered - not in my favor; ok, I guess the entire hospital wasn’t paying attention, but it feels like most of the surgery residents were.) I was starting to feel the slightest bit hopeful about next year, but not any more. Actually, I’m not so worried about myself, as about the people who will be getting called by me, since I’m clearly no good at assessi... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1395237 Wed, 23 Apr 2008 22:33:45 +0100 1395237 http://www.medworm.com/index.php?rid=1388974&cid=t_122957_109_f&fid=34750&url=http%3A%2F%2Fpsychcentral.com%2Fblog%2Farchives%2F2008%2F04%2F21%2Fsubstance-abuse-amongst-chefs%2F I love Hell’s Kitchen and Kitchen Nightmares, two Fox shows hosted by Gordon Ramsay, OBE, a British celebrity chef and very strong personality. Watching this season of Hell’s Kitchen reminded me of the stress and rigors that chefs in training regularly undergo. And something rarely mentioned on these shows — substance and alcohol abuse amongst student chefs. While on internship in New York, I had the pleasure of serving at the local county department of mental hygiene (yes, mental health is like your teeth — you need to floss your brain regularly to keep it clean!). In one of my rotations there, I had the pleasure of seeing a few clients who were attending the prestigious Culinary Institute of America. This is one of the premier chef schools in America, and if you... World of Psychology blogs http://www.medworm.com/rss/comments.php?id=1388974 Mon, 21 Apr 2008 13:52:15 +0100 1388974 http://www.medworm.com/index.php?rid=1389370&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F21%2Fcracked-open%2F The other day I saw my first ED thoracotomy. For those of you who aren’t medically fluent, that means splitting someone’s chest open in the trauma bay of the ER in a usually doomed attempt to save their life by cross-clamping the aorta to prevent bleeding, and dealing with fatal holes in lungs and heart. The success rate if this is performed for penetrating trauma (gunshot, stab wound) is commonly reported as somewhere near 5%. Perhaps not that much, although we did recently have a guy be discharged less than a week later. The indications are few and far between: for blunt trauma (which means that the attempt will probably be worthless, since if the person is dying of a blunt chest trauma it implies a massive disruption of the aorta, or something else impossible to fix) it&#821... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1389370 Mon, 21 Apr 2008 09:45:31 +0100 1389370 http://www.medworm.com/index.php?rid=1386132&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F20%2Fthrilled-2%2F I am so happy to be a surgery intern. I don’t know if I mentioned that lately. I am thrilled that I get to work with these patients, and no others, with these attendings, and no others. So what if I have to get to the hospital a couple hours before the sun rises; I’m there to see people with cholecystitis, and appendicitis, and aortic aneurysms, and cancer, and incarcerated hernias. Sooo much better than coming in later, and seeing people with hypertensive crises and strokes and weird metabolic disorders that got out of whack. These patients are all interesting, because they all have surgery in their past or near future - and it’s great. Sometimes, now, I get home while there’s still light outside. Perhaps I should stop cursing daylight savings time. It is, after al... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1386132 Sun, 20 Apr 2008 18:45:29 +0100 1386132 http://www.medworm.com/index.php?rid=1384102&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F18%2Feducation-takes-time%2F Because I was at the hospital late this afternoon (late as in, past civilian office hours), I got to see a complication in a patient our service operated on earlier in the month. It was the first time I’d ever seen or heard of, and it was a great experience to figure out what it was and then call the chief and treat it in the ER with him. Because we sent the patient straight home, the team members who weren’t in the hospital that late will never see it, and if things get busy this weekend, they may never even hear what happened. There’s a rumor floating around that the ACGME (bureaucratic organization that regulates all residency programs) may be looking at imposing 60hrs/week rules. I sincerely hope that this is an urban legend, since I haven’t had anyone close to ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1384102 Fri, 18 Apr 2008 23:46:23 +0100 1384102 http://www.medworm.com/index.php?rid=1380681&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F17%2Feducational-experiences%2F Once again, more studying got done than my brain can really stand. Learned all kinds of things about the biliary tract, including, in detail, what to do if you injure the common bile duct during a laparoscopic cholecystectomy. Which is actually fairly irrelevant, since although I’m afraid such an event may be in my future (incidence stable at 0.5% for the last several years), hepatobiliary surgery has never crossed my mind as a specialty, so I am sure I will not be in a position to repair the injury adequately. The general tenor of the lengthy textbook discussion was, interspersed with detailed instructions on how to repair every variety of injury, admonitions to refer such patients very early on to a major center and an experienced hepatobiliary surgeon. So mainly I learned somethin... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1380681 Fri, 18 Apr 2008 00:00:09 +0100 1380681 http://www.medworm.com/index.php?rid=1378106&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F16%2Fcognitive-dissonance%2F I’m beginning to think there’s either something wrong with me doing what I’m doing, or with how I’m doing it. I figured out today that the way the guys were talking about the attendings wasn’t bad at all. I know this, because today I was present when a fair number of the residents started to give their uninhibited opinion of a few other residents, and it was not pretty. I didn’t know what to do, except try unsuccessfully not to laugh. Granted, the people they were discussing have some peculiar mannerisms, and some of them are not the brightest pennies. But only one of them would I call downright irresponsible. The others are trying to do well, and just don’t quite match the other residents’ ideas of normalcy or success. So the senior resident... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1378106 Wed, 16 Apr 2008 22:47:39 +0100 1378106 http://www.medworm.com/index.php?rid=1375259&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F15%2Fline-upon-line%2F I’ve studied so much the last couple days I feel like I’m bursting. Apparently I’ve discovered the secret to studying at the hospital: don’t bring any other books in, and have nothing of the slightest interest occurring in the world, so that reading news sites and commentary is more boring than reading a textbook. Actually the surgery books are fascinating, especially since I asked the chief for some recommendations. I’ve now discovered a book I clearly should have been reading since the beginning of the year, Chassin’s Operative Strategy for General Surgery, which explains how to think about operations, and all kinds of details of practice that I’ve learned exist, by stumbling against them, but never really heard why they are that way. And then of... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1375259 Wed, 16 Apr 2008 01:40:31 +0100 1375259 http://www.medworm.com/index.php?rid=1372075&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F14%2Fconstant-vigilance%2F Lately we’ve been having some object lessons on the theme that just because you’ve closed the skin in the OR, the patient is not out of the woods. The other day we had a patient give a few good coughs as the anesthesiologist started to wake them up. Shortly afterwards the surgery resident (not me) noticed a fair amount of swelling at the operative site. A few moments of consideration led him to conclude that this was probably not just normal fatty tissue. He called the attending back in (this is where I entered, seeing the attending heading back, and figuring if he was that interested, it was worth me seeing too), and the wound was opened up to disclose a large amount of fresh blood. After clearing their way in, they found a bleeding artery, which would have led to serious prob... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1372075 Mon, 14 Apr 2008 23:39:55 +0100 1372075 http://www.medworm.com/index.php?rid=1368994&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F12%2Frandom-lessons%2F One effect of the chief trying to make me behave like a junior resident already is that I’ve realized I don’t know how to listen. I’ve gotten pretty good at giving reports on a patient’s history and pertinent data (at the beginning of the year I was actually pretty bad at this, I think partly due to being too nervous to talk straight, and partly due to being badly disorganized; I think I do a decent job now) - but listening to a detailed report is something else. Two of us interns were reporting to him about consults we’d seen. After I told my story, my brain kind of switched off. I heard the other intern talking, but it went past my head - until I realized that I was supposed to be reporting this to the attending in a couple of minutes. Whoops - I heard medic... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1368994 Sat, 12 Apr 2008 23:13:44 +0100 1368994 http://www.medworm.com/index.php?rid=1368566&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F12%2Falice-gets-excited%2F This month I’m working with some of the thyroid surgeons here. The other day they didn’t have anybody else to cover a thyroidectomy, so I got to help get started. After having been told all month that this was a case so complicated that it requires a senior resident to be in it, I figured, after reading the atlas extensively the night before, that the attending would just want me to retract while he did things, until a senior resident was available. And then there we were, the patient prepped and draped, and he just stands there, and the scrub tech hands me the scalpel. I really can’t get over that feeling, when I have the knife, and I’m supposed to start. I’m supposed to be doing the surgery. I cannot believe we’ve gotten to this point. Me with a knife.... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1368566 Sat, 12 Apr 2008 17:58:27 +0100 1368566 http://www.medworm.com/index.php?rid=1368025&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F11%2F1004%2F On the advice of my family, who have been a little concerned by recent interchanges on this blog, including my tone, which apparently comes across as much more cynical than I intend, even to my friends, I thought I would relate a couple of incidents from the last week: Medicine attending in the hallway: “Alice, thanks for your help with that guy the other day. I appreciate how quickly you came by to do the procedure.” Me: “Any time, Dr. Smith; you can always get me interested in sharp objects.” CRNA in the PACU: “By the way, Dr. Alice, after you left with the patient, the two OR nurses remarked how much they like to have you in the room. They said you’re the politest resident.” Me: “Oh, really? Mmm.” ER resident: “Wow, Alice, you ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1368025 Sat, 12 Apr 2008 00:51:57 +0100 1368025 http://www.medworm.com/index.php?rid=1358680&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F08%2Fstereotypes%2F I’m looking for opinions/advice on how to deal with people doing impressions of others. A lot of the guys here like to do “impressions” of various attendings. To me it feels like mocking them for being older than us, or for having a pet phrase or two, or for always approaching a problem in the same way. I’m not sure whether it’s mocking, though. They don’t do it as much about the attendings we don’t like as about the nice attendings. But of course they wouldn’t do it if the attending was around, and I’m pretty sure the attendings wouldn’t like it if they heard it. I wish I could stop these conversations, but I don’t know what to say. Ok, that’s the Dear Abby section for today. Now, some stereotypes from another angle: ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1358680 Wed, 09 Apr 2008 00:26:34 +0100 1358680 http://www.medworm.com/index.php?rid=1352428&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F04%2Fskipping-grades%2F The chief is not only teaching the students, he’s teaching me. He’s trying to make me act like a junior resident instead of an intern. So far, it’s been rather painful for both of us. I’m not sure at all what the boundaries are, and so far I’m erring by doing way less than he wants, rather than more. I’m just afraid that he’ll like it even less if I really start doing things on my own. But, with great patience, he persists in assigning me jobs that I think are beyond me, and refusing to just do them himself and get it over with. This is particularly altruistic on his part, since he’s not going to be here next year. I could see why the current third and fourth years might have an interest in me being well prepared for July, but this chief has ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1352428 Sat, 05 Apr 2008 00:02:46 +0100 1352428 http://www.medworm.com/index.php?rid=1350044&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F03%2Ffitting-back-in%2F The NG tube issue was addressed today, to such effect that the nurses started calling me to inform me that they had neglected to note the ins-and-outs for two hours. Which is of course what I ought to expect for making a nuisance of myself; but I’d honestly rather that they pay over-meticulous attention to the matter, than to ignore it entirely. I would rather be known as “that nasty surgeon who obsesseses about ins-and-outs” than have my surgical patients as neglected as they have been.  Our chief this month is a great teacher. He doesn’t make a big splash, being much less flamboyant than many surgical chief residents I’ve known; but he will quote you the numbers on almost any question you ask, and break down the ten different histological subtypes of any c... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1350044 Thu, 03 Apr 2008 23:29:01 +0100 1350044 http://www.medworm.com/index.php?rid=1347784&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F02%2Fwhat-not-to-do-with-an-ng-tube%2F Back in August, when I was still mystified about how an NG (nasogastric) tube works (which is rather shameful, because it only has two ends, and one extra piece in the middle, and is used in nearly 50% of surgical patients), I used to watch my chief checking fanatically on the NG tubes of patients on a particular unit. I couldn’t understand why she was always handling the thing whenever she walked by, and often holding it up to her ear. Now I know that one end of the tube goes down the patient’s nose into the stomach (ok, I knew that a long time ago), and the other end should be connected to a cannister on the wall, which should be connected to a mechanical suction device, which should be turned to on and set to medium suction. The purpose is to remove the saliva and gastric se... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1347784 Wed, 02 Apr 2008 23:34:17 +0100 1347784 http://www.medworm.com/index.php?rid=1344813&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F04%2F01%2Fwild-ride%2F My plan for the last night of March was to keep things quiet, get some sleep, and study up for a laparoscopic procedure that I had been semi-promised on my new service the next day. Semi-promised, as in, “X procedure. . . you do know how to do that, right? [alarmed] Have you ever done one of those?” Me: “Oh yes, sure - at least, I did one.” So every time the junior residents saw me, they egged me on to make sure I did the case, and every time the chiefs saw me, they expressed skepticism over the wisdom of the plan, coming off of nights, a complicated patient, and so on, and reassured me that one of them could do it if I couldn’t. Needless to say, after a very few of these conversations, I was quite determined to do the case no matter how tired I was. After all... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1344813 Wed, 02 Apr 2008 00:07:38 +0100 1344813 http://www.medworm.com/index.php?rid=1338382&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F31%2Fplanning-ahead-2%2F I spent a large part of the night, in my capacity as plastic surgery consultant, watching the trauma team and the neurosurgeons handle a stream of disasters. I would get a perfunctory consult, because of a broken orbit or zygomatic arch, or maybe a few small lacerations, but I wasn’t about to take up the time to look at the patient or sew things neatly while the neurosurgeons were discussing how fast they could get the subdural or epidural hematoma into the OR. Then there was the poor guy who came in with his face streaming blood and an unstable airway which took the longest time to get control of. I stayed around, because I figured with his face looking like that, there would be a plastic surgery consult forthcoming. When we finally got to the CT, everyone was amazed to see that the... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1338382 Mon, 31 Mar 2008 11:42:27 +0100 1338382 http://www.medworm.com/index.php?rid=1335498&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F29%2Flife-is-good%2F Jesus, I am so grateful to be doing this. Answering pages tonight, I was just happy that I get to be answering pages about surgery patients. In general, I am interested in what’s happening with them, and I’m familiar enough with most surgical situations to be able to give glib answers to questions. I am glad I get to take care of surgery patients. Life is good. And then, of course, I get to sew people up, too. I had a guy with the most complicated facial lacerations I’ve seen yet. It took me an hour and a half to finish. I think I did the best possible job with them. As messy as they were, he’s not going to be pretty, but hopefully not too horrible either. I bit my tongue and managed not to console him with the observation that scars look good on guys. He was the ni... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1335498 Sat, 29 Mar 2008 12:26:50 +0100 1335498 http://www.medworm.com/index.php?rid=1330068&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F27%2Ftreadmill%2F I spent all night admitting patients, so much so that I started to feel like part of the hospitalist team - one admission after another. There was one point where I had more than 10% of the ER waiting to be admitted by me individually, plus people already on the floor. At least they were all genuinely sick and deserving admission, which always makes one feel better about it, except that all the attendings were angry at me, for one reason or another, and most declined to answer my pages anywhere near the time I called them. And then I paged them a couple more times, which no doubt didn’t make them any happier. But since I’m sure they were at home either getting ready for bed or in bed, I don’t see why it should take twenty or thirty minutes to call back. Yes. And so on all... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1330068 Thu, 27 Mar 2008 11:13:16 +0100 1330068 http://www.medworm.com/index.php?rid=1327697&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F26%2Fnot-much%2F I have a new favorite set of dumb pages: two nurses apparently were trying to divide their work load, and were taking turns calling to ask me questions about the other’s patient. Then, an hour or two later, the other nurse would call to ask the same question, since apparently the division of labor didn’t extend to passing along the answer. I kid you not, they did this a couple of times last night. Silly me, it seemed simpler to just answer the question again than to get into it farther, so I didn’t say much. I am now officially tired of being on night float. I get to feeling like I’m walking through a valley waiting for ambushes. It’s not so much the patients I’ve been told about - this guy has low urine output, this one will need to be admitted, we&#821... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1327697 Wed, 26 Mar 2008 11:44:42 +0100 1327697 http://www.medworm.com/index.php?rid=1319706&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F21%2Fer-time%2F Congratulations to all the students who matched this week. Make the most of your time from now till July. My program filled its places with good people, and I’m looking forward to having them around in a few months. If I have to be a junior resident, they will make good interns. I made a new rule last night: no peanut gallery when I’m suturing in the ER. I know, that’s supposed to be a basic ground rule. The last few times I let it slide because the family member was somehow medically informed, and very interested, or because the injury was so traumatizing I felt like the patient needed to have more support than just my chatter during the procedure. However, I draw the line at three rednecks joking about matters while I’m trying to figure out which tiny pieces get c... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1319706 Fri, 21 Mar 2008 10:38:51 +0100 1319706 http://www.medworm.com/index.php?rid=1316891&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F20%2Fworrying-too-much%2F Due to some convolution of hospital politics (of which no one has really informed me; I deduce its occurrence by the effects on me), I find myself covering yet another service, about which I know even less than some others. Talk about sink or swim. Fortunately none of the patients I’ve handled like this have been truly sick yet, although they always come billed as something quite frightening, and it takes a little investigation to assure myself that they’re actually stable. Also the attendings are still new enough at having resident coverage at night that they actually appreciate my calls - unlike some other attendings, who now take us for granted and regard my calls as a nuisance. At one point tonight I found myself wandering into the ICU to check on one of my few patients th... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1316891 Thu, 20 Mar 2008 10:48:31 +0100 1316891 http://www.medworm.com/index.php?rid=1314600&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F19%2Ftips-for-medical-interns-homage-to-the-butterfly%2F Ok, that was slightly better. No nasty jobs from the floor or the ER. Fewer undesirable consults from the ER. (I fail, I really fail to understand, why an ER attending and senior resident would call me, show me a CT scan and an EKG, and ask me what we ought to do about it. Dude, I don’t know! I can see that there are QRS complexes, and that we don’t need to initiate the ACLS protocol. Beyond that, why are you standing there looking at me like I ought to solve the problem? The patient is in your ER! Doesn’t matter that a surgical service discharged him a few days ago; he and his ekg are in your ER now.) (I mean, I appreciate the vote of confidence, but my head isn’t that big; I know this is out of my depth.) I’m beginning to fantasize about adding a lecture to ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1314600 Wed, 19 Mar 2008 11:25:59 +0100 1314600 http://www.medworm.com/index.php?rid=1311634&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F18%2Frocky%2F Not a fun night. One of the services I cover did its usual crazy thing, admitting three patients right at sign-out, and spending five hours in the OR with one of them. I’m getting a little tired of working with the intern on this service. He means well, and I don’t think he’s deliberately neglecting things; but it’s getting to the point where I feel I have to double-check every point he tells me in sign-out, otherwise the nurses will be calling me at 2am: “this patient is for the OR today, did you mean him to be NPO?” “this patient just started coumadin, do you perhaps want an INR drawn this morning?” “this patient got a transfusion, would you like to check the hemoglobin count?” “this patient was admitted the other day, wo... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1311634 Tue, 18 Mar 2008 14:01:03 +0100 1311634 http://www.medworm.com/index.php?rid=1307990&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F17%2Fa-night-well-spent%2F It’s amazing how good a solid night of studying makes you feel. I only got paged about urology issues, which are also very satisfying, since they call for a quick, relatively risk-free and painless procedure which makes the patient feel better pretty quickly. So far I’m 30% of the way through The ICU Book (300/1000pp) (and only 3% of the way through The House Officer’s Guide to Urological Emergencies, which perhaps I ought to be reading more of, but somehow it’s not very gripping). I’m starting to have mixed feelings about the book. On one hand, it certainly contains such wildly relevant and fascinating subjects as, five continuous intravenous vasoactive medications (otherwise known as the five pressors, which about half the ICU population are on, and about wh... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1307990 Mon, 17 Mar 2008 10:50:05 +0100 1307990 http://www.medworm.com/index.php?rid=1306649&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F16%2Funprovoked-rant%2F I have two pet peeves about nursing reports. Not peeves, really, that’s too strong, but things I can’t understand. Number one, respiratory rate. When you ask for the vital signs, the nurses and aides always tell you respiratory rate. Which is good, because that’s what they were told to do. But it doesn’t really matter. First, in the hospital, respiratory rate is always reported as either 18 or 20, depending on what the nurse’s aide’s favorite number was for that shift. No one stands for one minutes and counts the patient’s respirations, and if they did it would be a tremendous waste of time. Secondly, the normal respiratory rate ought to be more like 12 or 14, or maybe 16 (and yes, it has to be an even number, otherwise there’s some serious p... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1306649 Mon, 17 Mar 2008 01:13:07 +0100 1306649 http://www.medworm.com/index.php?rid=1305870&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F15%2Fdonor-run%2F They sent me on a donor run today. A donor run is when a transplant surgeon travels to an outlying hospital to harvest organs. As far as I can tell, there’s a call schedule shared between the transplant surgeons in a large area, but going out usually implies that you plan on using at least one of the organs at your own institution. Usually this is the liver, since this is the trickiest to harvest correctly, and the surgeon likes to know that no useful pieces were accidentally left behind, and no unrecognized variant arteries were damaged. “They” sent me, as in the senior residents universally declined to go (bad time of day, weekend, weather, etc), and were secure in the knowledge that I would jump all over the opportunity if they let me. When I told the attending I was b... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1305870 Sat, 15 Mar 2008 22:56:24 +0100 1305870 http://www.medworm.com/index.php?rid=1305537&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F15%2Fenthusiasm%2F I’m going to have to stop talking about best days ever, because this is all good. The last few nights I and the other night people have been seeing one case after another of those “classic” things, where it looks like the textbook, sounds like the textbook, and even was caused by all the risk factors in the textbook. Not really famous cases, but I’m always tickled to find out that things exist in real life, not just in textbooks and legends. (Gallstone ileus, cecal volvulus, intussusception - that kind of thing.) Several nights back we had a med student on call, and there was a unique case going on. It was the first I’d ever seen or heard of, and the resident doing it also knew it only by anatomical drawings. The attending was a great teacher - ok, so he whisp... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1305537 Sat, 15 Mar 2008 13:52:59 +0100 1305537 http://www.medworm.com/index.php?rid=1303588&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F14%2Fa-little-better%2F Last night was slightly better, as in none of my patients crashed, I didn’t have to talk to any of the people involved in last night’s debacle, and that patient continues to do crazy things, but seems to be surviving them. One of his nurses paged me tonight: “Alice! I knew you would call me back. I’ve been calling cardiology and pulmonary, but they don’t answer me.” I guess sometimes reliable is better than - intelligent. I managed, that time, probably because I was more awake than the consultants had been. One of the services I cover is in a permanent state of disarray, so sign-out consists of: these patients had surgery today, those ones are having surgery tomorrow please make sure their papers are in order, I don’t know what these three people ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1303588 Fri, 14 Mar 2008 12:00:40 +0100 1303588 http://www.medworm.com/index.php?rid=1300845&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F13%2Funsatisfactory%2F At least on tests, when you manage a patient wrong, he goes away and stays away. In real life, my patient started having problems at midnight, and, despite me repeatedly choosing the wrong answer to every question, he wouldn’t stop. (I wonder why.) Sometimes, if you wait long enough, the problem will just go away. Sometimes, the purpose of a patient’s tachycardia seems to be to induce tachycardia in the caregiver; once it’s done that, it just goes away. Not my patient. I was trying not to be concerned, but after three stat pages from one of the worst floors in the hospital (within the space of two minutes, so it’s not like I was ignoring them), I decided I would have to postpone my other (equally) sick patients for the time being, and trust their more seasoned nurse... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1300845 Thu, 13 Mar 2008 11:32:53 +0100 1300845 http://www.medworm.com/index.php?rid=1298079&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F12%2Fi-need-psychotherapy%2F The thing I hate about sleeping in the hospital (and sometimes at home, too) is that I can never tell the difference between pages I really get, and the ones I just dream about. When I’m napping in the call room, I wake myself up every half hour or so (in addition to real pages) by imagining that my pager is going off, and that I’ve talked to someone about some emergency that I need to deal with right away. Then I drift back to sleep, and wake up five minutes later, panicked about having missed something, and trying to remember what the problem is. If I don’t wake up thoroughly at that point, I can spend the rest of the nap fighting subconsciously about that nonexistent page - or sometimes more than one. I even imagine whole conversations with nurses or referring resident... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1298079 Wed, 12 Mar 2008 14:36:05 +0100 1298079 http://www.medworm.com/index.php?rid=1295006&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F11%2Fstudying-is-dangerous%2F I was very wise last night, and made no remarks about having nothing to do - didn’t even let the word “bored” cross my mind, and that took some effort. As a result, I got almost no calls, and spent several hours curled up with The ICU Book. After some research, I have finally found a comfortable place to read. The call rooms are impossible: a boardlike bed with a single flat pillow, and an impossible chair, and, if you’re lucky, a metal cart for a desk. (I’m looking forward to graduating out of the intern call rooms.) But I have discovered the closest thing to a comfortable chair, in the same-day section of the recovery room. Unfortunately, now that I’m actually studying intently, I’m afraid I’m going to turn into one of those people who is a... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1295006 Tue, 11 Mar 2008 14:36:03 +0100 1295006 http://www.medworm.com/index.php?rid=1291226&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F10%2Fmangled-hand%2F Just spent nearly the entire night working on the most horrible hand injury I’ve ever seen. I brought some textbooks, planned to study conscientiously all night, got bored, said it too loudly, too many times, and of course got called by the ER. (Note: even more certainly than the taboo against saying “quiet night” is the rule against walking into the ER without having been called; it’s just asking for trouble, and you’ll always get what you ask for. I was going to look for some ivs to start, but instead I got this.) It was messy, nasty, bloody, bits and pieces hanging out all over the place. I didn’t particularly enjoy that part of it, but with the patient and family looking so horrified, it’s not too hard to keep calm, act like you’ve seen i... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1291226 Mon, 10 Mar 2008 10:33:39 +0100 1291226 http://www.medworm.com/index.php?rid=1289166&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F08%2Freal-surgery%2F I think I may have said this before on here - only once or twice - but this has been absolutely the best day ever. Better than all the previous ones. I got to first assist/perform a whole big case, one which I later realized is actually pretty rare because of the unusual approach the attending took. I was on call overnight, and you can imagine my dismay when (after a night filled with the almost cliched scenes of dark cars pulling up outside the ER and dumping out gunshot victims) just as I was setting out to round on my patients, on a tightly calculated schedule (calculated to allow for the longest possible nap prior to starting rounds, that is), I was paged by the ER. It was a patient for my service, so there was no way to duck. What was more, he needed surgery, urgently, so it took a wh... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1289166 Sat, 08 Mar 2008 22:56:47 +0100 1289166 http://www.medworm.com/index.php?rid=1286563&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F07%2Fthe-downside%2F I knew I was going to get in trouble. It involved a line that I couldn’t get in, and had to be fished out of by the chief. Ignominiously. It was the one line I’ve never yet succeeded in placing (radial arterial line, if you have to know), and a semi-unstable patient, and a medical ICU, whose nurses were more interested in standard operating procedure and paperwork than in taking care of the patient. The fact that the chief proceeded to explain to me loudly how and why he dislikes the MICU nursing staff didn’t really make things go any smoother. (Here’s one example of why the surgeons here mistrust the MICU: There is a code called in the MICU every one to two days. There is a code called in the surgery ICU once a month, if that. Maybe the patients in the MICU have wo... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1286563 Fri, 07 Mar 2008 13:10:38 +0100 1286563 http://www.medworm.com/index.php?rid=1283742&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F06%2Ftickled%2F I am, I regret to say, quite pleased with myself, which will no doubt get me in big trouble tonight. But for last night, it was great. They finished with a complex and unusual surgery and took the patient back to the ICU. Somehow he was now my responsibility. The attending and resident left to go home to sleep for a few hours, after leaving me with complex and detailed instructions covering most possibilities. Of course, as soon as they were quite out of the building, something else happened. He needed a chest tube, or rather, a pigtail catheter. This matters, because I was fairly sure I could do a chest tube, but I had never before seen a pigtail put in (it’s a much smaller tube for draining only air out of the chest cavity, when you don’t expect to find blood, and thus don&#8... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1283742 Thu, 06 Mar 2008 14:23:12 +0100 1283742 http://www.medworm.com/index.php?rid=1281146&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F05%2Findecision%2F I’m still not doing well with this independent judgment thing. I really hate having to put myself on the line: take responsibility for having gathered all the relevant facts, for having weighed them correctly, and for having chosen the right course of action - without checking with anyone else first. It’s kind of like the difference between practice test questions, when you can look at the answers right away and see how you did, and the real test, where you just have to plunge ahead, and wait a few months to find out whether you were right or wrong. That’s the nature of being a doctor, but after spending eight months accustoming myself to checking everything with a senior, no matter how confident I am, and being chewed out if I fail to do so, this is a little bit of an ad... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1281146 Wed, 05 Mar 2008 13:05:44 +0100 1281146 http://www.medworm.com/index.php?rid=1278593&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F04%2Fscore-one%2F My job description this month calls for a lot of independent assessment, decision making, and interaction with the attendings. Half the time, I have to call very senior staff by myself, no junior resident to run things by first, and I find them making their decision based on my reporting. Apart from burns (where I knew the nurses knew almost everything, and would tell me what they thought needed to be done), this is the first time I’ve had so much responsibility. I spend a lot of time agonizing over whether it’s worth calling the attending with this issue, or whether it can wait; whether I’ll get in more trouble for waking him up at 1am and it turns out to be nothing, or more trouble if I don’t call and then things go bad; whether I’ve gathered absolutely ever... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1278593 Tue, 04 Mar 2008 15:48:22 +0100 1278593 http://www.medworm.com/index.php?rid=1275055&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F03%2F03%2Fhamfisted%2F I found myself in the OR at the beginning of a big case. A rather stupendously big case, to be precise - ten times over my head. But the attending was starting by himself. So I asked: “Would you like another pair of hands?” Sure, he said, scrub in, there’s always room. Back in medical school, I learned the [very] hard way to give warning before trying to do something (close fascia, place a line, etc) that I’d never done before. Sometimes, it seems that I still need to give warning that I’m only an intern. Here, I didn’t. For one thing, I kind of assume that the attendings will recognize which residents have been around the OR a lot, and which ones are relatively new faces. Wrong assumption, apparently. Five minutes in: “Tell me again, what year are... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1275055 Mon, 03 Mar 2008 11:53:05 +0100 1275055 http://www.medworm.com/index.php?rid=1272612&cid=t_122957_93_f&fid=35707&url=http%3A%2F%2Fhemodynamics.blogspot.com%2F2008%2F03%2Fsnapshots-of-va.html For two weeks, I'm on nightfloat at a Veteran's Administration hospital, a dark quiet place at night. ***There's a big photo of the president at the entrance. Each night as I walk in, I think, I hope that photo looks a lot different next year.***There's no cafeteria at night. There is a room full of vending machines. I had a 20 dollar bill and I wanted a Coke Zero. In a quiet hour, I walked down to the emergency department and asked the clerk if there was a cashier anywhere who took payments at night, so I could get change. He sent me to the security desk, staffed by a VA police officer who told me that there was no cashier anywhere, and no change machine he could think of. I thanked him, and started to turn to walk away. "But there's a stamp machine," he said; "You could buy a stamp and i... hemodynamics blogs http://www.medworm.com/rss/comments.php?id=1272612 Sun, 02 Mar 2008 21:22:00 +0100 1272612 http://www.medworm.com/index.php?rid=1266747&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F28%2Fbackwards%2F Attendings are funny. The vascular surgeon complains about having to repeat operations on the same patients over and over. The bariatric surgeon complains about his patients’ difficult personalities, and how difficult it is to get them to breathe properly after surgery. The colorectal surgeon complains that he hates the smell of poop. I feel like saying, hmm, isn’t that a necessary aspect of the specialty you chose? It’s probably just a continuation of the residents’ behavior. Psych residents complain about having to see silly suicide attempts in the ER. Medicine residents complain about having to go to every code in the hospital. Peds residents complain about their patients’ parents. Surgery residents complain about getting stat consults all day. What we real... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1266747 Fri, 29 Feb 2008 00:31:10 +0100 1266747 http://www.medworm.com/index.php?rid=1263572&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F27%2Fdont-run-with-scissors%2F I discovered for the first time today (at least as a doctor) that it is possible to be tired of doing surgery. Of course, the fact that I spent enough time in the OR to reach this conclusion was wonderful. I also hope that when I progress to doing something more than holding one instrument and (this is what distinguishes me from the medical student) having to stay alert enough to agree when the attending says, “Don’t you think this is the right place to cut?” or “I don’t see anything else bleeding, do you?” and so on, I will have more stamina. Today I tried falling asleep again in a dark OR. Fortunately the only thing I was supposed to be doing was holding pressure on something, and since the attending didn’t say anything, I figure I managed to bot... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1263572 Thu, 28 Feb 2008 01:01:32 +0100 1263572 http://www.medworm.com/index.php?rid=1260088&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F26%2Fperspectives%2F I just gave some auto parts salesman the dumb blond story of a lifetime, if only I were blond. Somehow, I became persuaded that my headlights weren’t working - burnt out, rats ate the wire, I don’t know what I thought had happened. So finally I made time to stop at a parts shop to get it fixed. Me: There’s something wrong with my headlights. I think I need new ones. Mechanic: Make, model, year? . . . Ok, how many cylinders, four or six? Me: Cylinders? I have no idea. Mechanic: You have to know that. Me: I have not the faintest clue about anything related to cars. That’s why I came here. Mechanic: Ok, fine, is it your high beams or your low beams that are burnt out? Me: Huh? Mechanic: Where I come from, we’re in the habit of turning the lights off and on. Which... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1260088 Wed, 27 Feb 2008 01:03:40 +0100 1260088 http://www.medworm.com/index.php?rid=1256419&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F25%2Fburied%2F My service got hit by an avalanche today. We halfway saw it coming, knowing what the OR schedule was, but half of it was through the ER. The only good thing is that almost everyone was genuinely sick. It’s much more fun to take care of sick people who get thrown into your lap, than not-sick people who have to have the paperwork done anyway. I got to spend a fair amount of time in the OR, with one case which was at my level, and one senior-level case which I was thrilled to land in because there were simply no other residents free in the entire hospital. Of course, I paid for it by drowning in floor work whenever I left the OR. I was pleased beyond words to be operating, but it was frustrating not to be able to take care of my patients as carefully as I usually like to. We got a few d... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1256419 Tue, 26 Feb 2008 01:56:12 +0100 1256419 http://www.medworm.com/index.php?rid=1252910&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F24%2Flooking-ahead%2F It’s fun to see how my role is starting to shift as the end of the year comes in sight. The seniors are talking about the interns as residents, not referring to us as a separate group. The juniors are making more and more comments about “when you’re doing this next year,” not teasing us, as it was at the beginning of the year, but out of a careful desire to pass on information that we’ll need, and that they need us to have in order for things to go smoothly. The chiefs are more and more focusing on their plans for after residency - traveling to look for houses, finalizing new jobs, and spending more time than I care to think about filling out licensing applications for whatever state they’re moving to. The mental and chronological gap that they leave is ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1252910 Sun, 24 Feb 2008 17:51:24 +0100 1252910 http://www.medworm.com/index.php?rid=1246741&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F20%2Fhitting-the-books-again%2F Things are still slow around here, and that’s fine with me. For the first time in a while, I’m actually working only 12 hours a day. I got to enjoy looking at the snow today. I haven’t had this few patients to see in a morning since I was in medical school. I’m also studying for Step 3. Common wisdom says it’s not necessary to study for this test, but since it takes two days, I would hate to have to repeat it. Besides, I’m a compulsive perfectionist. Although the score doesn’t matter to anyone, for my own private satisfaction I’d rather it not be too much lower than the first two USMLEs I took. Actually, my main problem in studying is that I know too much about a few things. Colon cancer? I could recite you the staging in detail, and all the ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1246741 Wed, 20 Feb 2008 22:46:39 +0100 1246741 http://www.medworm.com/index.php?rid=1236402&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F15%2Flap-chole%2F A few days ago I was allowed to do my first laparoscopic cholecystectomy (gallbladder removal). For once, I knew about the case the day before, so you can be sure I spent the evening studying Zollinger’s atlas of surgery on that subject. (Zollinger, as in Zollinger-Ellison syndrome (a tumor that secretes gastrin, causing uncontrollable production of acid, leading to intractable stomach ulcers). The Dr. Zollinger was a professor of surgery at OSU. I had attendings in med school who had trained under him, and they used to tell us horrifying stories of his mental cruelty and sometimes downright physical violence towards residents and students. Now I can never think of the pancreatic endocrine cancer syndromes, let alone open this key textbook, without picturing the most dramatic of thos... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1236402 Sat, 16 Feb 2008 00:49:27 +0100 1236402 http://www.medworm.com/index.php?rid=1230462&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F13%2Fstill-smooth%2F Life just keeps getting better. The attending is starting to leave me to finish some cases (ie close up afterwards, but still it’s a responsibility; and I don’t know whether or not I’d like to know what the OR staff think as they watch me slowing down even more to do things meticulously in his absence). The chief remarked, “I’m tired of doing these cases. I’ve had enough to last me a lifetime. You go do the next one.” More laparoscopic experience there. I think that attending is starting to run out of patience with my awkwardness. I hope he can stand to have me around a couple more times this month, because I’m starting to hit the learning curve, and get a little more comfortable with the instruments. Then, we had an ICU patient with very po... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1230462 Thu, 14 Feb 2008 00:22:01 +0100 1230462 http://www.medworm.com/index.php?rid=1223849&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F11%2Fwalking-on-air%2F I went into the OR at 7:30, and the next thing I knew it was 3pm. I had no idea the cases were taking that long. I’m sure to the medical students, watching and doing nothing, every minute crawled, but I feel as though the day disappeared. This is truly “living the dream.” Who cares how late I finally got out of the hospital? I got to assist with a laparoscopic procedure today. This time I ended up trying to move an instrument “against the camera,” which means that rather than the camera looking straight forward, and you trying to move your instrument forward, you find yourself moving the instrument towards the camera’s “face,” so that in addition to the usual disorientation of doing something with your hands while looking in a different direc... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1223849 Tue, 12 Feb 2008 01:00:46 +0100 1223849 http://www.medworm.com/index.php?rid=1216638&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F07%2Flegends%2F Not much action the last couple days. I’m enjoying the chance to explore the hospital’s library, and do enough studying during the day that I don’t have stay up with the books at night. On the other hand, I’ve been dutifully trying to read the chapters on anatomy, so I’m also getting a fair amount of sleeping done during the day - semi-unintentionally. I figure ought to read about liver anatomy, with all those confusing segments and branches, because it’ll be years before I ever get to see any, and even then there won’t be much. Somehow asking the hepatobiliary surgeon to explain the subject doesn’t seem like a promising approach. Several chapters later on, though, is a long and fascinating section on the treatment of hepatic cysts caused by ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1216638 Fri, 08 Feb 2008 01:54:10 +0100 1216638 http://www.medworm.com/index.php?rid=1205019&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F04%2Fat-last%2F This probably ought to count as the best day of the year so far, since I spent more time in the OR than I can remember doing since the plastics rotation. I got to do some stuff, too, including laparoscopy. I thought that was completely thrilling, just to be holding a laparoscopic instrument. I’m afraid the attending, who wanted me to move it in a semi-controlled fashion (not careening off the bowel and any other structures in the vicinity, or threatening to), and then actually pick things up and hold them, found me rather frustrating. He was quite nice, and did nothing but make helpful comments as I struggled for ten minutes to both hold the camera, and then at a 180-degree angle, pick up an object and move it in three dimensions. Not unsurprisingly, he did seem relieved when a seni... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1205019 Tue, 05 Feb 2008 01:32:55 +0100 1205019 http://www.medworm.com/index.php?rid=1198820&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F03%2Fresponsibility-2%2F A friend at church gave me a copy of Atul Gawande’s new book, Better: A Surgeon’s Notes on Performance. I don’t enjoy reading Gawande’s writing, I think for two reasons: he writes so well it makes me depressed about my inelegant efforts here, and he takes his work so seriously that it makes me feel inadequate and guilty about all kinds of things I remember doing, or not doing. He is not a comfortable author for doctors to read. For instance: responsibility. When I was a medical student and something was missed, I could always tell myself, “You should have noticed that, you should have taken care of that, you should have drawn attention to that - but it’s ok, that’s what the residents are for. In the end, it was their responsibility, not yours.&#822... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1198820 Sun, 03 Feb 2008 21:34:00 +0100 1198820 http://www.medworm.com/index.php?rid=1196916&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F02%2F02%2Fa-fresh-start-2%2F The last day of the month was too overwhelming to write about. I found myself sitting in the nurses’ station at 8:30pm, asking them, “Tell me what I forgot to do.” As soon as I put my coat on, they remembered; which was good, because it was important. I’m going to miss the charismatic attendings on that service, but it will be nice to have a smaller workload, and spend a few less hours in the hospital every day. The next day was wonderful, a great way to start the month. They had a hard case that they actually invited me to scrub into and assist with. I managed to demonstrate a small amount of manual dexterity, at least enough to reassure myself. The chief I have this month is a really great guy, fair to the juniors and interns, and well-informed in a non-threatenin... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1196916 Sat, 02 Feb 2008 17:30:40 +0100 1196916 http://www.medworm.com/index.php?rid=1190124&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F30%2Fjuggling%2F Beepers are instruments of fate. Sometimes, when I get to do something really great, like put in a line, or scrub into a case, the beeper will be completely silent for exactly the length of time I need, and then go off nonstop for ten minutes when I’m done. Other times, like today, it’s exactly the opposite. I checked in with my team in the OR, then headed out to see a consult from the ER. On the way, I met another attending setting out to do a fairly large case with only a medical student assisting. He invited me in, but of course I had to go to the ER first. I ran down, thinking, if I do this fast enough, I can get back before he gets very far in the case, and he seemed friendly enough to let me in partway through. I did that consult in about seven minutes. It wasn’t to... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1190124 Thu, 31 Jan 2008 02:01:16 +0100 1190124 http://www.medworm.com/index.php?rid=1187291&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F29%2Floving-my-patients%2F We’ve now arrived at that peculiar time of the month, when the service is drawing to a close, and I am divided between sadness to leave the patients I feel responsible for, and attendings I’m now slightly comfortable with, and eagerness to move on to something new. At the beginning of the month I was disappointed in the high hopes I’d had for this rotation, but in the last week or two I’ve enjoyed the work that I actually am doing, rather than focusing on what isn’t going to happen. At last, with only two days left, I dare to recognize that I’m actually doing a good job. Which in the world of an intern means that it’s time to switch to a new subject about which I know nothing. But perhaps it is time to move on. Today I was utterly disgusted to disc... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1187291 Wed, 30 Jan 2008 00:49:51 +0100 1187291 http://www.medworm.com/index.php?rid=1184798&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F28%2Fbringing-up-memories%2F I think 8:30 is the latest I have ever stayed in the hospital yet this year. It felt kind of crazy, walking around to check on the patients, saying “goodnight, I’ll see you in the morning,” and considering that “morning” means 4am, less than eight hours away. But I don’t particularly mind. I picked up a case in the ER, and got to take it to the OR within a few hours, and do a lot of the procedure. Quite satisfactory. Of course it was another one of those ugly, boring cases that no one but an intern wants; but I had fun. That took till the end of the afternoon. Then, I got called to the ER for an intubated patient. I was trying to figure out what could cause a surgical patient, no vascular issues, to present, intubated. That’s not usually the scenar... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1184798 Tue, 29 Jan 2008 02:18:35 +0100 1184798 http://www.medworm.com/index.php?rid=1179989&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F26%2Fpatient-care%2F Considering the horrifying buildup the other residents had been giving it, the ABSITE wasn’t that bad. That is to say, I recognized the subject matter of more than half the questions, rather than the 30% I had been expecting. Now it’s over, and I can spend one evening without feeling guilty about needing to study. One of my friends, back when I was a pre-med student, started off wanting to go to medical school. Halfway through college, she decided that she wanted to be able to spend more time with patients, so she switched to nursing, even though it cost her some semesters. With her perpetual enthusiasm and cheerfulness, I’m sure she’s a wonderful nurse. Anyway, I’ve been thinking that the great thing about this year is that, without exactly setting out to, I ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1179989 Sat, 26 Jan 2008 23:40:53 +0100 1179989 http://www.medworm.com/index.php?rid=1179343&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F25%2Fall-thumbs%2F I didn’t stop running all day today. Surgery with the attending actually wasn’t too bad. He threw me a couple questions I knew the answers to, and then mainly stuck to the technical matters at hand. The more time I spend around the OR, the more I realize how perfectly hopeless I am with any kind of tools. It’s kind of pathetic, really. I still, after nearly three years, struggle to move the armboards on the OR table, let alone attach leg-pieces or stirrups. The OR staff is still trying to explain to me how to tighten and loosen screw mechanisms. Every time I disassemble the piece we’re trying to put on, or lock down the piece we’re trying to take off, I want to say that this is why I’m not doing orthopedic surgery; but that would sound like I shouldn&#82... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1179343 Sat, 26 Jan 2008 01:51:46 +0100 1179343 http://www.medworm.com/index.php?rid=1176317&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F24%2Fpointless%2F Spent way too long in the hospital today, more tomorrow, and the test on Saturday. Beautiful. I had resolved to spend the two hours left in my evening by studying for tomorrow’s OR cases (and give up on studying for the test), since by some fluke I get to scrub on the tiniest ones. Halfway through my proposed reading, however, I suddenly grasped the meaning of my chief’s lifted eyebrow when I stated that since only three types of pathology were on the OR schedule, I should be able to get enough reading done tonight. He meant that this is the attending who notoriously will not ask about the subject you’re operating on, and thus presumably (hopefully) know something about. He’ll ask about everything else instead. So basically preparing for tomorrow’s ordeal is ... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1176317 Fri, 25 Jan 2008 01:24:41 +0100 1176317 http://www.medworm.com/index.php?rid=1173627&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F23%2Fpriority-check%2F Another good day. I was running nonstop (although I admit that my commitment to patient care has declined to the point that I did take ten minutes for lunch, and thus missed a few items of scut, which will keep for tomorrow), and didn’t get much done other than put out fires. Bless their hearts, the nurses had a whole list of jobs for me (reorder the pain medicine, reorder the iv fluids, change the blood pressure meds to po, and so on)  none of which I considered essential except the ones needed to keep the PCAs (patient controlled iv narcotics - very popular with patients and staff) running. We had a sweet little old guy go into afib with rapid ventricular response. The junior and I pushed some iv meds on the unmonitored floor (to the glee of the patient’s nurse, a very sharp... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1173627 Thu, 24 Jan 2008 01:07:06 +0100 1173627 http://www.medworm.com/index.php?rid=1170496&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F22%2Flightbulb-moment%2F No doubt this is extremely lame, and I ought not to be confessing it in public. But as a result of studying for the inservice exam, I have finally grasped the significance of FeNa (the fractional excretion of sodium in the urine, calculated as (urine sodium/creatinine)/(plasma sodium/creatinine) ), and urine sodium, and urine electrolytes, relative to acute renal failure. This is one of those topics that people have been asking me about for the last three years, and I always gave them a blank stare and some kind of mumble. (The answer to the equation is either more or less than 1%, so you have a 50% chance of guessing the right one in a yes/no question.) Then they would give me some rapid and forceful explanation about its extreme and vital importance, which I of course didn’t under... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1170496 Wed, 23 Jan 2008 01:45:28 +0100 1170496 http://www.medworm.com/index.php?rid=1163767&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F20%2Fsatisfied%2F Best call day ever. I got a whole case for myself. Admittedly just a giant abscess, but so disgusting that the attending didn’t even bother scrubbing, just gave vague directions from the background about where to cut, and the senior resident let me dive in on my own. After all, the tissue was so messed up that a couple millimeters deviation in the incision wouldn’t make much difference in the long run. It was neat, because I had admitted the guy, evaluated him myself and concluded he needed to go to surgery (it took me about five minutes, looking at him; the other surgeons took one glance and started calling the OR folks). I had also gone through the consent with him, which was a little difficult, because I knew the abscess was bad enough that there might be complications comin... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1163767 Sun, 20 Jan 2008 17:07:07 +0100 1163767 http://www.medworm.com/index.php?rid=1162099&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F18%2Fminor-details%2F I was thrilled today to be assigned to a couple of short, dirty cases. These were the kinds of things that made me seriously consider not going into surgery, just to stay away from this part of the body and its problems. Two things have changed my mind. My attendings, very dedicated, serious people, take this stuff seriously; which kind of destroys negative connotations. I think one of the problems I had as a med student was the attending who specialized in this stuff; he made the residents miserable no matter what they were doing, let alone these cases. Also, I’m so hungry for cases, I promised myself I would enjoy this stuff if they threw it to me; so I did. I’m getting a better handle on the floor patients. Somehow, after spending months away from a straightforward general s... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1162099 Fri, 18 Jan 2008 23:32:51 +0100 1162099 http://www.medworm.com/index.php?rid=1156881&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F16%2Fcovering-up%2F Today one of the attendings, bless her heart, took pity on me standing around the OR, and let me do the minorest, dirtiest part of a dirty case. But I was happy. I’d never done that particular procedure before, and she let me fumble around with things and take my time. Then I got paged from the ICU (which I’m not responsible for): “Please, are you taking care of Mr. Jones?” I used to just refer those calls to the senior resident, to whom they belong. But I’ve learned to ask first: “What’s the problem?” If they want an order to continue the current iv fluids, I can do that; or if the patient is crashing, I want to know it. “His blood pressure is dropping, and he’s tachycardic and anuric, and I’ve paged the senior five times a... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1156881 Thu, 17 Jan 2008 00:14:39 +0100 1156881 http://www.medworm.com/index.php?rid=1154128&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F15%2Fpile-on%2F Things were going ok till this afternoon. Then, two attendings, the chief, and a fellow decided to educate me, in the usual surgical tradition; spurred on a little, I think, by having had a long and frustrating case in the OR. They asked what I wanted to do about a patient with a problem. I suggested a solution - the wrong one of course, and I realized it the minute the words were out of my mouth, but too late. The attending wanted to know why, so I gave him my best shot at a reason. He then in an ironical and speculative tone of voice mentioned several other very pertinent facts which pointed to a completely different course of action. Since he was right, I said that we should do his idea instead. And then he laid into me for changing my mind, and gave me a very nice lecture (but one whic... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1154128 Wed, 16 Jan 2008 01:41:44 +0100 1154128 http://www.medworm.com/index.php?rid=1150912&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F14%2Ftwiddling%2F This service continues to be frustrating. Although the attendings are busy enough to give me plenty of floor work, the way the resident team is structured, there are enough people around that I can’t foresee any circumstance which will let me scrub in for the rest of the month. I can be as efficient as I like (and finally, I seem to have nailed a system for rounding on a full complement of patients by 6am, and having most of the orders and discharges done by 7 or 8am), but all it gets me is more time to stand in the OR with my hands folded, watching from a sterile distance. I do it, of course, because that’s how you show interest and enthusiasm, and I fantasize that if the attendings notice me a) having all the work done, and b) coming to watch them at every opportunity, perh... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1150912 Tue, 15 Jan 2008 01:08:23 +0100 1150912 http://www.medworm.com/index.php?rid=1148306&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F13%2Fovernight%2F Last night I got definite proof that all the rest of my fellow interns have forgotten the prime directive, which is to plan ahead to prevent calls. I think every single person who was allowed to take anything by mouth developed a headache, and didn’t have any tylenol ordered. (OK, there were other pain meds, but the nurses and patients and I all agreed that they were overkill for a headache.) Of course, none of them did it at the same time. The nurses were calling me literally every ten minutes - starting, of course, only after I decided to try to sleep. After an hour or so of that, the ER called me. The poor intern down there started off to give me a complete history of the patient, starting with the symptoms that had caused him to be admitted two weeks ago. “Bill. Stop. He&#8... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1148306 Sun, 13 Jan 2008 22:45:41 +0100 1148306 http://www.medworm.com/index.php?rid=1147059&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F11%2Ftime-for-saturday%2F Today was a Friday kind of day. Some of my patients were angry at me again (maybe I need to start thinking in terms of borderline personality, although I hate that psych nonsense; it would make their vagaries easier to take). Everyone declined to be discharged, and my attendings seemed to be scouring their offices for people to admit. I somehow found myself in the ICU with a sick patient for part of the morning, which also threw off my plans to keep the floor in order. The senior residents were struggling too; somehow it’s worse all around when no one on the team is on top of the game. The lab produced terrifying results to some lab tests, which sent me scurrying all afternoon to take care of the people; and then the repeat labs came back stone cold normal. So I called the lab and a... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1147059 Sat, 12 Jan 2008 00:21:53 +0100 1147059 http://www.medworm.com/index.php?rid=1142876&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F10%2Fwaiting-2%2F I don’t know what happened overnight, but this morning everybody was quite happy. All my unreasonable patients professed themselves quite comfortable and ready to go home. Some of the others inquired with concern about how much I work. It’s funny to see the lights go off in people’s heads, after they’ve spent three or four days in the hospital, and had me wake them up before 5am, and check on them at 6pm and in between, every day, and they suddenly realize exactly how many hours a day that is. If it makes them any happier about being woken up at 4:30 in the morning, it’s all to the good. All of my attendings seem to have recovered from Christmas, and have gigantic OR schedules for the next while. Busy enough to keep me quite occupied, but sadly just unbusy eno... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1142876 Fri, 11 Jan 2008 00:36:05 +0100 1142876 http://www.medworm.com/index.php?rid=1140327&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F09%2Fmore-to-learn%2F First time ever: I felt obliged to go spend some free time in the library, reading Mastery of Surgery, a massive set of two volumes which combines discourses on the pathogenesis, presentation, and diagnosis of every single surgical illness, with lengthy instructions and illustrations on how to perform every procedure which could possible be desired - and many which are now only of historical interest. Senior residents have told me that when dictating a procedure for the first time, one could simply read passages of this book out loud, and be correct. I have read this book before; but today was the first time that I finished reading a chapter, and was immediately paged to go see a patient with that problem. I felt extraordinarily intelligent while talking to him, and to the attending. I sha... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1140327 Thu, 10 Jan 2008 00:02:19 +0100 1140327 http://www.medworm.com/index.php?rid=1138176&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F08%2Fdodging%2F Sparse pickings on the blog these days, because there’s not much happening, and what there is would be too clearly identifiable, or too impolitic, to say. I could tell stories about consulting for medicine teams, but I won’t. They were actually trying very hard today, and it’s not fair to be sarcastic because we would rather they had called us 24 hours earlier. Being rude now that they have called us would only discourage future communication. In general, I’m behaving more and more like a surgeon, and I’m less and less able to perceive it or to object to it. After all, this fact/question/intervention is urgent, and it’s my job to make sure it happens. The nurses are still smiling, so it’s not too bad yet. One of the more irrepressible nurses is try... Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1138176 Wed, 09 Jan 2008 02:02:22 +0100 1138176 http://www.medworm.com/index.php?rid=1137409&cid=t_122957_83_f&fid=36527&url=http%3A%2F%2Fcutonthedottedline.wordpress.com%2F2008%2F01%2F08%2Freal-life%2F Conclusion: This is why God made PCA pumps (patient-controlled analgesia: small doses, and if you’re drowsy you can’t push the button, so theoretically less likely to overdose; although I’ve seen it come pretty close, too). (Source: Cut On The Dotted Line) Cut On The Dotted Line blogs http://www.medworm.com/rss/comments.php?id=1137409 Wed, 09 Jan 2008 01:09:08 +0100 1137409