Metamorphosis of another kind

I used to keep a journal in med school--you know, the paper and pen kind. Actually, I still do, for the things I want to keep private.

In any event, I was reading through it the other day, and it was striking how many of my entries began by mentioning a humongous roach flying around my bedroom. Usually I had tried to kill it with bug spray, and then lost track of it. And I can't sleep when a roach has gone MIA somewhere in my house. So I would write, in order to keep myself awake until it showed itself again. It was one of the few constants in med school, and really only my OB/GYN rotation was worse than dealing with the roaches.

It's true, I'm a slob. But the big flying southern roaches have nothing to do with how clean you keep your house, and everything to do with how well sealed off it is from the humid air and wet soil outside. They love moisture, and they aren't afraid of people. In fact, if disturbed, they'll fly at you rather than away. Ugh, I still have flashbacks.

It was particularly awful to go back to roach land after living for a year in Seattle, where there are hardly any bugs at all. And definitely none so brazen. Back in Texas I had always made a point of living in well-sealed apartments with good pest control. But I had forgotten about the issue when I was looking for a place to live in New Orleans--not that there was any such well-built housing in my price range, anyway. It cost me untold hours of sleep as a med student, and its absence has without doubt been the best part of internship.

Likely the only thing better will be the end of internship.

Dear lungs:

You are the only reason my patients ever die. Please cease and desist from all activities which detract from your primary duty of oxygenating blood and excreting the acidic end products of glucose breakdown.


Sincerely,

Your patient's intern

Oh my God I'm so sick of dealing with anything non-neurological. I seriously don't know how I'm going to make it through two and a half more weeks of this. Not to mention that it's killing my good record for not readmitting patients to the ICU.

I have two patients who keep getting better, then worse, then better, and so on. There were three, but over the last three days, each of them has successively crashed, and yesterday one had to be readmitted to the ICU. He was within a day or two of discharge, and we had consulted ID for recs on outpatient antibiotic therapy. The ID service had requested a thoracentesis on the guy's pleural effusion, to make sure it wasn't an untreated source of infection. I'm a little pissed off that they even asked for it, because clearly the guy was clinically improving, and we were asking them for simple recs on an infection we had already identified and were evidently treating appropriately. We were not asking them to go hunting for an occult infection, nor was there any indication to do so. But we can't ignore a request like that, when the guy clearly does have a pleural effusion that hadn't been fully investigated.

So our chief did it, and the patient was fine immediately after the procedure. But then an hour later I went to check on him and found him in respiratory distress. Paged the chief, called a rapid response, recruited a couple of nurses for vitals, O2 and an EKG, and got set up for an ABG. He was tachycardic and tachypneic, but with palpable radial pulses. He'd gotten his post-thoracentesis chest x-ray moments before I arrived, which looked like a pneumothorax but not a tension pneumo. Most of the lower lung fields were whited out, a big change in comparison to the pre-thoracentesis image. He obviously needed a chest tube, but what kind and where to place it was not clear. So I called the radiologist, and he read it as a hydropneumothorax. I'm sure I could have placed it myself, but at this hospital chest tubes are the province of thoracic surgery. But they were busy, so the R2 ended up putting it in. Initial output was about a liter, and his hematocrit dropped significantly, so he went to the ICU for closer monitoring. I was so pissed off at the whole ridiculous sequence of events. One stupid, overly cautious consult rec, and now the guy has to spend an extra two weeks in the hospital.

Not to mention that, this entire year, I've never walked in on a patient that sick who wasn't already being tended to by the nurse or the rapid response team. Seriously, if I hadn't happened to walk in right then, that guy would likely have died before anyone else came in to check. And what's up with getting a chest x-ray just moments before? How can you come in, blithely shoot your x-ray (for which, by the way, you have to ask the patient to take a deep breath), and leave without noticing that the patient looks like he's asphyxiating? This guy's distress was so obvious that it needed no medical training whatsoever to see.

Ironically, the very fact that I've never had to deal with this before as an intern is a testament to how good the hospitals are at which I work. But I was still pretty shaken by the whole series of events.

I remember vividly the last time I had a patient get that sick on me. I was a third year med student, on my medicine rotation at the VA. It was a spinal cord injury patient who had come in for shortness of breath. We worked him up in the ER and found post-obstructive pneumonia from advanced lung cancer, previously undiagnosed. The guy had been a nonsmoker all his life. A couple days into his hospital stay, I had promised him I would come talk to him about what was going on. There had been some discussion that day about making him DNAR, but no paperwork had been filled out. I had forgotten to stop by that afternoon before going home, but it had been impressed upon us the importance of keeping the promises we make to patients. Plus, the guy was dying, and had been such a shit to his family that they refused to have anything to do with him no matter how he'd turned his life around. I mean, can you think of a worse way to die?

So I came back after dinner to talk to him, thinking I would just sneak in and out to keep my promise without making the other students look like slackers. But I found him in respiratory distress with an O2 sat in the 60's. He already knew his diagnosis was terminal, so I asked him if he wanted me to try and do everything possible to help him live right now, and he nodded. So I checked the chart for DNAR paperwork, and finding none, went to get the nurse to call a code. He died in the code, and the senior resident wasn't too happy that I had called one, since his diagnosis was terminal. Not to mention, what the hell was I doing at the hospital at nine o'clock at night when I wasn't on call? My explanation sounded unbelievably lame, even to me. I could just hear them all thinking "what a f-ing gunner."

Except I'm pretty much the opposite of a gunner: I try not to look like I'm working harder than the other people in my group, while still getting all my work done thoroughly and well. But that whole medicine rotation, my patient list was like a cancer ward. Plus I had a bunch of super-complicated patients with obscure diagnoses. Meanwhile my fellow students' patients were all pretty much SNF candidates, waiting on placement. It's funny how the luck of the draw (which it totally was) can still lead to such a skewed distribution.

So I had a few patients die on that rotation. But it's funny, I never cried over a patient's actual death. I only cried about the things we did wrong that hastened it. Which I guess is a good thing in a neurosurgeon. There's too much death to function adequately, if you find even inevitable death seriously disturbing. But it should be very upsetting to have made it happen sooner.

In other news, I have an interview back in hurricane country next week. It's a solid program with pretty much all the things I'm looking for, so hopefully they'll offer me the spot. The one intern there that I know from the trail is a good guy. But it's literally the opposite corner of the country from here, so I'm spending twelve plus hours traveling for five or so hours of interviewing. Kind of crazy.

If I don't end up getting that position, it's unclear what I'll be doing next year. What I had thought was a solid backup plan is no longer a sure thing. 47 more days to figure it out.

The scenic route

I've been asked to talk about how I became interested in neurosurgery. My story is a bit atypical, so I'm not sure how much it will help anyone else. Nonetheless, here it is.

Basically since I've been old enough to have interests of my own, I've been interested in how the brain does all the things it does. Neuroscience, psychology, psychoactive drugs, neurology, neurosurgery - the entire spectrum interests me. Even during my long detour into pharmacyland, it was psychiatric and neurologic disease that I wanted to work with, and not the pharmacotherapy of internal medicine diseases. Although that was my official specialty. Even when I was in management, it irked me to no end that my boss would not let me have the neurology building pharmacy services to supervise. She knew I wanted to go to med school, and at the time my plan was to become a neurologist. She did throw me a bone: the neurosurgical ICU. And I had toyed with the idea of becoming a surgeon, back when I was the surgical ICU pharmacist, but never really thought it was an option.

Then Tropical Storm Allison flooded the Medical Center, and nearly destroyed the hospital where I worked. During the recovery, the administration brought in a consulting firm to assist with rebuilding the pharmacy (which had been totally destroyed). A team of young, clinically oriented managers had just been created, and all of us knew that it was only a matter of time before the old boss would be asked to step down, and one of us would succeed her. I was the lone manager who wasn't jockeying for position - I didn't care about anything except making things better in the pharmacy and getting into med school. Nonetheless, I kept getting the critical, organizationally most visible projects. The consulting firm wasn't happy about the fact that here I was being groomed to take over, and my goal was to do something else entirely. So they gave me an ultimatum, and I quit.

I got offered some really sweet management jobs after that, but I had learned a lesson: not to be seduced by things that don't help me reach my goal. Pharmacy management is neither a neuroscience-oriented pharmacy job, nor a route to medical school. So I decided that I would not take another permanent job until I found one in neurology or psychiatric pharmacy.

I'll never forget my interview for the neurology position I found. After all the talking was done, the other neurology pharmacist took me on a tour of the areas where I would be working. At the time, the neurosurgery residents were trying to do a lumbar puncture on one of their patients, and we went in to watch. The guy was large and became combative and incontinent of stool just as they were getting started. So everyone was trying to hold him down while someone went to get restraints. I'm standing there in my interview suit, thinking, "Ok, I can stand here like an idiot, or I can take my jacket off and help." So I took my jacket off and grabbed one of his legs. When the restraints arrived, I put one on the leg I was holding and locked it. I'd never put restraints on before, but it wasn't too hard to figure out. Finally, they gave him some Ativan and he started to calm down. But they ended up postponing the procedure.

It took them a long time to call and offer me the job. But eventually they did, and I got to spend a year and some change basically shadowing a bunch of neurologists. It was totally unlike what I expected. Part of the job was to attend the daily neuroradiology conference. At first, I could barely tell the difference between a CT and an MRI, but I used to play this game in conference where I would try to figure out the abnormality before the neuroradiologist pointed it out. I got pretty good at it. But I found it frustrating that we never did anything with the diagnosis, once we made it.

And then one day I went with a resident to a joint neurology/neurosurgical radiology conference. It consisted mostly of attendings, and they would look at the scans and discuss how best to fix the problem. On that day, it was the vascular neurosurgeon talking about the feasibility of an EC/IC bypass for a patient of ours with moyamoya disease. The idea that these kinds of things could be done made me realize that what I really wanted from medicine was to be able to fix a problem, not just diagnose it and throw some drugs at it. And that was the day I started seriously considering neurosurgery.

So, like a number of people I know, I started medical school with neurosurgery already on the radar. Unlike most them, however, I had a fairly accurate idea of what it entailed, and was far less blinded than most by the glamorous facade it seems to have in the eyes of the public. Most students starting med school only know that facade, and as they make their way through med school, they realize it's not for them.

Most attrition is related to one of the following issues: a) the person discovers a surpassing interest in something else, b) their Step 1 score is low, and to try and overcome it is more work than they want to do, or c) they discover what it's really like, and realize that it entails sacrifices they're not willing to make. Despite the trash talk that goes on among applicants jockeying to match at the big name residencies, the reasons people don't become neurosurgeons are mostly A and C, not B.

And I already knew, walking in the door of med school, that C would not be an issue for me. Reason B was preventable, and mostly a matter of making good choices about how to spend my study time. So that left reason A.

I had learned already not to cross things off before fully considering them, so I set about exploring other fields. Anesthesiology was the first to go, thanks to an early exposure program at my school. After that was medicine. The contrast in personality was evident. I'm good with the words, but words should lead to action, not more words. This drives me nuts about medicine people: they never use one word when twenty will do.

So I was left with surgery, peds and the non-patient-care specialties. I had the least experience with pediatrics, so I made an effort to get to know that field. In the preclinical years, all of your interviewing and physical exam teaching is done by people on the medicine side. So whenever I had the option, I would ask to work with pediatricians instead of adult medicine doctors.

Meanwhile, I was also getting to know the faculty in my school's neurosurgery department, going to their conferences and watching their surgeries. And nothing else I saw or did could compare.

Then third year rolled around, and Hurricane Katrina. From a neurosurgical perspective (although not really any other), it was the best thing that could have happened to me. Because of it, I ended up doing my surgery rotation at UT Houston, and my neurosurgery rotation at Baylor. In the course of these met some really good neurosurgeons who are also great people, and got involved in a well-run research lab. It was a done deal from that point on.

Some people decide on surgery first, and then find that along that spectrum, neurosurgery is the best fit. Some people decide on neuroscience, and gravitate toward surgery. I did the latter.

Can't stop the clock

53 days of internship remaining...

Back on General Surgery this month. The first day on service was incredibly painful. Not only was I taking over for an intern who was actually a mostly-trained general surgeon in another country (and thus finds everything in general surgery easy and straightforward, unlike me), but I also had a schedule that day which literally required me to be in two places at once for most of the day.

In any event, things calmed down after the first day. Part of the problem was that I'd never really had to pre-round on a general surgery service since the point at which all the vitals and allied health notes were switched over to the new computer system. So the first day, I was completely unable to find large chunks of the info I was expected to have available on rounds. I know exactly where to find it on the old system, but that knowledge is now useless.

On a side note, it sucks to be an intern during your hospital's changeover from one EMR system to another that's completely different. You have to know all the details, and when they're suddenly somewhere else, and buried in a non-physician-friendly format on a program that loads information slowly (this is a key point), patient care can easily be compromised.

The slow-loading program is what's currently pissing me off. It takes twice as long as it should to collect the data I need in the morning, and most of my time is spent waiting for pages to load and display information. And the pages purporting to provide an "MD Summary" are frustratingly incomplete, superficial and completely un-tailored to the patient's primary service. The programmers were clearly lacking sufficient breadth of physician input.

If it's going to be that slow to load, there should be some way for me to create a tab for myself that automatically loads all the information I need, as a surgery intern, and allows me to add or delete things as my data collection needs change on various services and with various supervising residents and attendings. Man, if I could do that, I'd be Super-Intern. There would need to be a huge variety of things I could pull into my tab, and I'd have to be able to control the format to a reasonable extent, but I know it can be done. It's just a matter of institutional will to make it happen.

Theoretically, it's possible to do that with notes. But I find the process to be prohibitively difficult and the options on formatting and information retrieval limited. It's OK for attendings, whose formatting needs don't change every month. But for residents, and particularly interns, on whom the brunt of data gathering and documentation rests, it's actually more efficient just to wait for the pages to load. Seriously.

Anyway, when I had initially looked at the schedule for this rotation, it appeared that I would be in clinic nearly every day. Thankfully, that has turned out not to be the case. I have dedicated clinic time on Tuesday and Friday afternoons, and occasional duties at other times when the load is particularly heavy. And the clinic I work is a vascular service, with an attending who mostly does research, and loves to teach.

So it's not as bad as I expected. Although it seems that most of what I learned about vascular disease in medical school is wrong. I don't know what kind of vascular program Tulane had--I don't recall meeting any faculty who were vascular surgeons, but it's possible I did and just forgot. I did see some truly horrendous vascular disease in New Orleans, but I don't recall seeing any that had been surgically treated. It's a real gap in my education, and the subject is interesting enough that some remediation is welcome at this point.

But the hospital I'm at is notorious for its bureaucracy, which makes any rotation here just that much more painful. The joke is that JCAHO ran screaming from the building when they came to accredit this hospital, because we have more policies, procedures and forms to fill out than even they want to deal with. And the internal culture is such that everyone seems more concerned about getting the proper form filled out than anything else related to patient care. Also, if you like having some autonomy as a junior, you won't get it here. The sphincter tone is substantially higher at this hospital, no matter how competent a resident you are. I don't know if patient care is any better, but the leash is definitely shorter. It's kind of funny - I had more autonomy my first three months as an intern than I do now in my second to last.

I figure if I just pretend I'm a med student again--albeit one with order-writing authority and twice as many patients--I should get through this rotation without running afoul of anyone. I was frustrated then at not having authority to make even low-level intern decisions. That's all I get to make on this service, so that should be just about right.

Anyway, in less than two months it'll be all neurosurgery, all the time. So things are about to get a whole lot more interesting. And two rotations is nothing, compared to the eleven I've already done.

Possibly the worst job in healthcare right now

By the way, I added a bunch of pharmacist blogs to my blogroll. I spent a few hours the other day laughing hysterically at all the stories, which for the most part are strikingly similar to my own experiences as a retail pharmacist. Standing for 14 hours straight? check. No time to eat lunch or even pee, and exempt from employment laws regarding these? check. Broken A/C in the middle of a Texas summer? check. Customers shooting the messenger? check. Clueless store managers? check. Drug addict coworkers, forged prescriptions, fake phone ins? check. Moms who bring in their screaming kids so you'll fill their prescription faster? check. Providing free triage for the local ERs and doctor's offices? check.

I've seen just about every kind of lie or scam there is, to get a drug.

Good times.

Retail pharmacy was an education in telling people things they don't want to hear, and the importance of addressing agendas as well as questions. And you get such swift and unequivocal feedback whenever you've made an error. If you inadvertently got suckered in some way, there'll be at least 10 more people who try to do it again before your shift is over. So if you just pay attention, you get very adept at reading people, and telling the difference between a suspicious but true story, and well-told, plausible lie.

Anyway, these blogs are very well-written and accurately reflect the situation in retail pharmacies across the country. In many ways, it's worse than a surgery residency, including any subspecialty. It's not as bad, in other ways, but on the whole I'd choose a neurosurgery residency over retail pharmacy any day.

Where's MY Dilaudid?

Note to self: don't schedule interviews after you've been up all night.

It was bad enough that my face has been peeling for the last couple of days from a sunburn. (yeah, I know, I'm still pale. It sucks.) But the entire interview was just the interviewer talking and me alternating between facilitating comments and inane, sycophantic, mealymouthed babbling. Seriously, there was zero personality on display today. Not that I'm the life of the party on a regular day, but this was more like the death of the party.

And last night just was awful. I seriously think those nurses hoard all their questions and problems until I'm on duty. No, really: the night before last, this one nurse paged the team pager, and upon finding out that the day intern was still on duty, declined to ask her question and instead asked when they were going to sign out to me, saying her question could wait till then. The intern got off the phone and had this look on his face like, WTF?

I'm officially off duty at 6am, but I've usually signed all the patients out by 5:30. So this morning I had three hours to kill between signing out to the day interns and the interview. That's just enough time to lay down for a nap and instead fall deeply asleep. Which would be bad, for obvious reasons. I don't use an alarm clock to wake up in the morning--fear of oversleeping is really the only thing that wakes me up effectively. And using an alarm clock lessens the fear, so paradoxically, I'm more likely to oversleep. The only realistic option was simply not to sleep at all.

But I was mentally exhausted from the constant barrage of questions about patients for whom my role is simply to put out fires. I do tend to overstep that role pretty frequently. But then again, very few patients ever try to die on my watch, and I can count on one hand the number I've had to transfer to the unit. So maybe I have decent clinical judgment. Or maybe I'm just lucky. Or maybe everyone's extra vigilant around me, because I suck that badly. It's hard to tell, from my perspective.

All I know is that my patients tend to get better rather than worse. And despite the fact that night float royally sucks, when it's done diligently, I think it's better for the patients than call and cross-cover. However, at the end of a week on the trauma service, I feel like I'm the one who needs some pain meds. (not that I would ever actually take any, but you get the point.)

If I were making a mistake, I would know it by now

When I was about a semester into pharmacy school, I got a job working as an IV tech in a hospital pharmacy. At the time, I was also about knee deep in campus politics (not yet up to my eyeballs, as I would later become), had just disentangled myself from my biggest relationship mistake ever, and was living with a roommate who would become one of my best friends in college. My parents looked like they were going to get back together, and I was doing pretty well in my classes. Life was good.

Except I was having second thoughts about pharmacy. I was not like the other students in my class. I was not from a small town. I had not gone to junior college. I did not still wear bows in my hair and dress up for class like it was pledge week at the sorority house. I did not wear a multi-carat rock on my left hand. And I was not politically conservative, or a fundamentalist Christian. I remember sitting in class one day thinking, "who are these people, and am I going to be dealing with colleagues like this the rest of my career?" The idea was very disturbing.

So started watching the pharmacists at my work. I listened to what they talked about, and tried to understand what their lives were like, and paid attention to the scope of their daily activities. It was the fall semester at that time, and by the following spring, I knew I had made a huge mistake. But I was already in pharmacy school, and I couldn't face the thought of how many years it would take to drop out and do something else. Not to mention that I had no idea what else to do.

Add to this the fact that my health professions advisor had told me, before I ever even applied to pharmacy school, that I struck him as more suited to medicine than pharmacy. But I replied that no medical school would consider a student with my grades, and he agreed. Still he tried to get me to take classes that were pre-med and not really pre-pharm, like anatomy, and the lab where we had to dissect a fetal pig. But I just wasn't ready to go that route at the time.

And I still wasn't, three semesters into pharmacy school.

So I did what any student so involved in campus life would do: I went to the career counseling center for help. I knew about it because a friend of mine had worked there, and he recommended one counselor in particular as very talented and helpful. So I went to see her, and explained my situation, and how I had no idea what to do with my life. She had me take a couple of tests to determine my personality type, and my interest in and subjective sense of skill at various activities. In the meantime, she asked me a bunch of questions about myself and my background.

I remember one in particular--she wanted to know who my heroes were.

"What do you mean, heroes?" I said.
"Someone you admire, whom you want to be just like," she said.
"There isn't anyone," I said.
She said, "You need to find a hero, someone you can use as a role model."
I told her that made no sense to me. "Everyone has their flaws," I said, "and most people have admirable qualities, even if on the whole I don't like them."

This was clearly not the answer she was expecting. But she acknowledged that this was probably correct, and said that perhaps I could instead identify someone whom I mostly admired and follow in their footsteps. I said that was all well and good if you can find someone like that, but I hadn't run across anyone whose life I wanted mine to be like.

I knew I was being difficult, and yet I wasn't lying or exaggerating. Seriously, were most people unable to solve on their own the kind of problems amenable to such simpleminded advice? There was no dearth of people willing to serve as my mentor, the problem was that I didn't want what any of them wanted for me.

She did say one thing that I found helpful, and it was that getting a pharmacy degree didn't mean I had to be a pharmacist. And that even getting a license and working as one didn't mean I had to be a pharmacist my whole life. I could use it to support myself on the road to becoming something else, and it wasn't strictly necessary to figure out right now what that something else would be.

Nonetheless, it was clear from this discussion that I would need to obtain a graduate degree in something. So things went along for a few semesters as I explored various options for postgraduate education.

Mostly as a result of false advertising, I eventually tracked into the doctoral program in pharmacy. The administration at my school made the career options sound a lot like the practice of medicine, and I still wasn't ready to think about medicine itself. But the closer to a medical curriculum our lectures became, the more interested I was in the subject matter. And then on our clinical rotations it was painfully obvious that I was interested in everything about medicine except the drugs. I felt like an incompetent idiot most of the time, and I just couldn't make myself care. Everyone was convinced I would fail my licensure exam and disgrace the school. But as it turned out, I had one of the higher scores that year.

So I graduated, and got a job. Three months after getting my license, I realized that the doctoral degree did nothing to mitigate the overall mistake of pharmacy school. If anything, it made things worse. As I later found out, my school had a reputation for producing aggressive clinicians. People who were vastly overtrained for even the widest scope of practice allowed to a pharmacist. These were people who took pathophys with the med students, and outperformed them on their own tests.

Anyway, I bit the bullet, and decided to go to med school. It was very difficult to get anyone even to look at my application, but eventually I got in. And now, here I am, almost a year into residency, and I know it was the right decision.

Why do I bring this up? Because there's a resident here who is switching out of neurosurgery. He told me back in November that he was thinking about it, but asked me not to say anything, so I didn't. I thought at the time that it was a reaction to the crappy treatment he was getting from his fellow residents. And I felt somewhat guilty for the fact that I actually got along with them pretty well, and was having a great time on the rotation. I also wondered if I would suddenly be picked on and mocked mercilessly next year if I were the PGY2, despite getting along with everyone now.

But I recently heard via the grapevine that he had actually been having second thoughts, even during his intern year. And that made me feel better, because I'm done with my neurosurgery rotations for the year, and I have none whatsoever.

So what's the point? Well, it's this: people know very quickly when they've made a mistake. They may drag things out for a while, trying in every way possible to salvage the time and effort they've already spent. In fact, some people never have the courage to back up and change course, and so they learn to live with being less happy than they might have been. Or they find other things to distract them from their unhappiness. But if something is a mistake, you know it, pretty much as soon as you start down the path.

It took a lot of guts for that resident to get out of neurosurgery at this point in training. But it was the right choice for him. Really, --and I wish someone had told me this when I was 22-- if you can't stand the taste of lemonade, don't waste your time making it. Just give the lemons back.

Schadenfreude

It's been a fun couple of days in the ER. Exhausting, but definitely interesting. Yesterday we had a guy come in with an extremely large and deep neck laceration that miraculously missed every major nerve and vessel. So the task of sewing it up fell to me, the intern.

It was not a simple task. The laceration was Y-shaped and ran at a 30 degree or so angle to the plane of the overlying skin, with a dog ear at one end. Last July I wouldn't have had a clue how to approach the problem, but now it seems easy. That's what three months of plastics will do for you. The scar won't be as pretty as I could have made it--he's a guy, and he wanted bragging rights for the most stitches among his buddies. So I obliged, and closed it with closely spaced interrupted sutures instead of the running subq I'd have done otherwise.

We'd had a patient the previous evening who'd taken a pretty bad beating to the head, and had a multitude of 1-2cm lacerations across his occiput that were bleeding profusely, along with some facial fractures. Not coincidentally, he was also drunk and high on a number of illicit substances. He'd been talking on and on to me about how he was a God-fearing man, and had lost his woman, and loved her so much and wanted her back, etc. etc. All the while I was injecting lidocaine in his scalp in order to irrigate his wounds and staple them up, which was taking some time because they were all under his C-collar and he wasn't really cooperating. But then the craniofacial intern came down to see him. For some reason, the patient took an instant dislike to said intern, and stood up on the bed, pulled off his IV and started cursing at all of us. For a moment, the patient and I made eye contact, and I thought for sure he was going to launch himself off the bed at me. So I very slowly backed up a few steps and walked behind the curtain. And like an infant with no sense of object permanence, he forgot I existed, instead launching himself out the door of Resus 1 and toward the back desk of the ER.

He was tackled by security, and eventually sedated and restrained, and the other intern and I continued with our respective tasks. It's so much easier to irrigate and staple lacerations when the patient is snowed. If he hadn't gone nuts on us, I'm not sure I could have done it.

Then today I put in a chest tube on my own, with correct placement and without complications. And then I did my first femoral arterial stick for a trauma code, and got it on the first try. And all shift I was getting lines and blood draws when other people couldn't. In fact, we had a patient with exactly the same invisible roly-poly little veins as my 2nd year classmate/blood draw victim, and I got a line on my first try. Now that's a milestone.

Now if I could just get an opportunity to put in a central line...

Hema-tomato

Alright, I'm still alive. If a bit loopy. My head still hurts, but after some Tylenol it was much better. In retrospect, we probably should have scanned my head. I take two different drugs that affect platelet function. Neither of them are common enough to send up an immediate red flag in most surgeons, so I don't fault anyone for not picking up on it, but I knew better. In any event, no harm done.

And I have one more thing to say about the whole being a trauma patient thing: that backboard? Not uncomfortable at all. Seriously, my empathy is gone. Unless you actually broke something, in which case I still feel for you.

As for my minimally injured self, I'm now more worried about my knee, which has developed a pretty impressive hematoma. It's actually a distinct pool of blood in the subcutaneous tissue. I know that has a different name, but I can't remember it. I've gotten one before, and it took weeks to resolve. Although that one wasn't over a joint, so there wasn't the ongoing trauma that's happening everytime I bend my knee now. It's very uncomfortable. Although not painful, and the knee itself works just fine.

Fortunately this occurred on the last of my four shifts in a row, so I have a couple of days off to recover.

Hardheaded

I guess I'm not quite as much of an old lady as I thought. I had my own little GLF today (that's ground level fall, for you non-medical types) in the ER. I tripped over a cord that was suspended about 5 inches above the ground between a patient bed and the wall. I had nothing to grab and catch my balance, so down I went. I hit my forehead, the side of my nose and my left cheek right on the zygomatic arch. Given the number of years I took prednisone, I ought to have broken something. But no, all I had was a piddling 1cm laceration in the middle of my forehead. It bled profusely enough to freak everyone out, but turned out to be very superficial.

If I had been a real old lady, I would have had some significant facial fractures, and possibly a subdural hematoma. I guess I could still have the latter, but it's probably just a concussion. We didn't CT my head, so who knows? But there was no loss of consciousness, and I remember the fall in detail, so anything worse than a concussion is very unlikely.

Strictly speaking, the laceration didn't even need sutures. We could have dermabonded it, and it would have been fine. But I'm just vain enough to want the smallest scar possible, and dermabond wouldn't have approximated it as well. So our trauma doc, who also happens to be a plastic surgery resident, put in a couple of tiny sutures, and I got a nifty Bugs Bunny bandaid on top. I figured the sutures would be a lesson in empathy for my patients.

Nothing could be further from the truth.

Seriously. I warn people about the burning sensation with lidocaine infiltration, and still they yell and curse because it "hurts so bad." Please, people, get a grip. It's not that bad. Also, it doesn't take 5 minutes to work. I was numb within the amount of time it took her to open the suture tray and put sterile gloves on. Also, if you just drip lidocaine on intact skin, that's pretty much enough to numb the epidermis. Granted, it was a tiny and superficial laceration. But still. People who think it hurts have clearly never experienced any real pain.

Afterward, I finished up my paperwork and was sent home. Now I'm just trying to stay awake so that I'll hear the phone when it rings. I've assigned some people to call me throughout the morning to make sure I'm not dead or comatose from an epidural bleed. It's a little dramatic, but, doctor's orders. Although I'd probably know already if one were present. And a mid-forehead bonk doesn't seem a likely mechanism to me.

As with most things, either it is or it isn't going to happen. But ouch, my head sure does ache. I guess that's what I get for having such a hard head.

Are the other interns not operating AT ALL?

Yesterday the case numbers for the intern class were sent out to all of us. I was surprised to see that I actually have more cases than just about any other non-categorical intern. I'm actually on par with most of the categoricals.

I find that very hard to believe. From my perspective, it seems like I hardly operate at all. It's got to be that the other interns just aren't entering all their cases.

Seriously, I've done most of the rotations where the intern gets operative time: burns, plastics, and formerly, trauma (not so much now that they've reconfigured the intern assignments). And I know that a number of my fellow interns have done those rotations as well. Since that time I've done anywhere from 2 to 10 cases per rotation--significantly less than I hear other interns are doing on the rotations in question. Yet their case numbers are one-half to one-third of mine.

It's true that I am very meticulous about recording my cases. More so, I'm sure, than most interns. I've recorded nearly all my cases since the beginning of my core surgery rotation in medical school (however, only my cases as an intern are logged in the database). So it's pretty much second nature to collect an ID label for every patient I operate or assist on. And probably the prelims for other specialties are tracking their cases in specialty-specific databases. But I have more cases than all but one of the undesignated prelims, and by a long shot. And they should definitely be recording their cases in the same database as me.

This can't be right.

Out of season

I finally feel human again after yesterday's ER shift. The previous night's crew started getting hammered with traumas at about 4am, and when we came in at 7am, every bed was full on the trauma side. Five patients whose charts contained only their story and an incomplete physical exam were signed out to me by the prior night's intern (who is a friend of mine, so I told him I'd do his neuro exams if he'd do the ABIs. Except then I had to teach him how to do ABIs, so it didn't actually save me any time. But no big deal.)

This wouldn't have been any kind of problem, except that the traumas kept coming, and coming, and coming. We would only just be done with the primary survey and maybe trauma films when the next trauma would roll in and overhead we'd hear the dreaded words "Trauma doc! New patient in Resus 2." At one point it got so ridiculous I just starting laughing hysterically (and inappropriately) whenever I heard it. By noon the whole team had this dazed, punch-drunk look on their faces. It finally slowed down at about 2pm that afternoon.

But it didn't really end. Instead, it transformed into a steady stream of garden-variety trauma punctuated every hour or two by major, attending-level, multi-line-and-tube, open chest, headed to the OR ASAP injuries.

Amazingly, none of them died in the ER. Possibly one was brain dead before arrival, but no one left the ER without a pulse on our watch. And I got to put in a chest tube, hooray! But then they opened the chest, which kind of defeats the purpose of a chest tube. Oh well. I'd never seen an ER thoracotomy before, and yesterday I saw two. One was even a clamshell (a bilateral thoracotomy, which basically lifts the entire chest wall up off the heart and lungs). It was funny, because we'd just been talking about that earlier in the day.

I guess, after watching all of that, I can see how general surgery would appeal to people. The gen surg chiefs and fellows and attending basically swooped in and got the patient's heart working again, and whooshed him off to the OR in heroic fashion.

But I'm sure that every field has cool and exciting things about it. And if you consider only that, there are a number of fields that look interesting and rewarding. But I think you really have to like the mundane stuff as well, because that's at least 95% of the job. And that's where neurosurgery wins the game, for me. Operating is fun, at some level, regardless of the body part. But it's all the other stuff that makes the difference.

Anyway, it took me until 4pm just to dig myself out from under the charts that had been signed out to me that morning. But then my own charts were much easier to finish, and surprisingly, the major trauma chart was easiest of all. It was just a chronology of events and exam findings, and since the patient was only in the ER for half an hour, and I was at the bedside the entire time, it was easy to document what happened, when and why.

But I was totally wiped out when I got home.

Laparoscopic brain surgery? I don't think so.

Extremely slow day in the ER. Thank God. Yesterday was busy enough for two days. In fact, I think I've developed biceps. And perhaps lost a pound or two. Although I could be imagining either of those things.

I have vacation coming up, and I'm trying to decide where to go. Maybe Mexico. Definitely someplace warm and sunny. The problem is, I spent a large portion of my savings interviewing for PGY2 spots, and I don't know if I can afford to go anywhere.

Wednesday a bunch of the interns, including me, have a training session on how to do a laparoscopic cholecystectomy. Now I ask you, my 3 or 4 faithful readers, when would I ever have occasion to actually do a lap chole? Would it not be a far better use of my time to attend neurosurgery grand rounds that morning instead? Not that I would mind playing around with the laparoscopic instruments on any other day, and I did beat all those general surgery gunners at one station of the laparoscopic skills competition on my surgery rotation in medical school (in fact, none of the winners were actually going into general surgery, if I recall correctly). But it bugs me that I'm required to learn how to do this operation at a time when I could be elsewhere, learning something I actually need to know.

This feels like work

Now I really know why they call it the Zoo. Oh my god, that ER is crazy. And yet I still haven't seen it anywhere near the worst it gets.

I went to a school where we didn't have to draw blood or place Foleys or insert IVs. I have placed a few Foleys, and art lines, and done bits and pieces of chest tube insertions. But aside from my mandatory blood drawing lesson back in 2nd year of med school (where I had the misfortune of trying to stick a classmate with tiny little roly-poly veins and a generous amount of subcutaneous fat, meanwhile she got to stick me with my supersize antecubital and thin skin), I've never actually had to place an IV or draw any labs. So I've learned a whole bunch of new skills in the last few days. And my arms are sore from rolling patients to check their backs.

It's pretty fun, despite that. Although I'm glad I only have one month of it--I think it would get old after a while. I seem to spend most of my time trying to keep track of data, rather than diagnosing or treating anything, and trying not to let any of my patients languish too long without making any progress either upstairs or out the door. So far I've been able to keep up with my trauma sheets, and not get too far behind with writing down all the exam results. A few months ago, one of my fellow interns got stuck in the ER two whole hours after his shift ended, because he hadn't kept up with his charting.

My goal is to be out the door by 7:15 at the latest.

The weird thing is, traumas here are handled completely differently than they were at the hospital where I did my trauma surgery rotation. Or maybe the med students there just weren't as involved as they are here. Here they basically do what the interns do, the only difference is they have to have their charts and any medication orders cosigned. From a student perspective, it's a much better experience.

So it's been interesting and fun so far. But not a substitute for neurosurgery.

Time and patience: luxuries I don't have

I just met one of my neighbors down in the laundry room. Apparently it's laundry night for everyone in the building--the washers and dryers have been full every time I've gone down there. My neighbor was having the same problem. She's much nicer than I am about it, though. She kept coming in to check, waiting for the other people to remove their laundry.

Not me. If the machine wasn't running, that laundry was out of there and I was doing a load of my own. It's the universal rule of shared laundry machines: if you don't remove your laundry, someone else will. I have no patience for people who hog the machines all night. Especially when the cycle is done and the clothes are just sitting there.

I knew I'd regret renting a place without its own washer and dryer. But the rent was reasonable and the parking was free, so I guess something had to give.

I've had the last couple of days off. It's very strange to have days off in the middle of the week. This is the first time that's happened my entire intern year. Well, except when I was on vacation. I keep looking at the calendar to make sure I'm really not working. But no, my first shift is tomorrow morning.

I realized today as I was out and about, that I finally feel like I live here. This whole time, I've felt like I was just visiting. Like there was no point in making real, more than just work friends. Or socializing, or getting involved in any kind of community activity. Unfortunately the reality of my situation hasn't changed, and my best option is to find a spot wherever one exists. Which unfortunately is not here.

But at least some of the baggage left over from med school is gone. And I'm thankful for that.

Unfinished business

So this morning it was brought to my attention that March is sleep awareness month. For some reason I find this hilarious. As if being aware of the need for sleep was the only thing necessary to increase the amount of sleep we get.

In any event, my month on neurosurgery is over. I have mixed feelings about being done with this service. On the one hand, it's the end of neurosurgery for the year. And I still love neurosurgery. This is the only field where I have as much energy at the end of a call day as I did at the beginning. On the other hand, the level of interrupting, patronizing and other disrespectfulness from one of my teammates was getting intolerable. For most of the rotation, the chief would make him shut up, but since about Wednesday of last week that hasn't been happening. In fact, there was a palpable shift last week in interpersonal dynamics, and I can't put my finger on exactly what changed. But it definitely did, and although the difference isn't obvious to an onlooker, things haven't been quite right since. And now the month is over. So it won't ever get sorted out now.

Anyway, next up is ER at the 'Zoo. Which should be fun.

Yes, Virginia, that WAS a flying pig

It occurs to me that I'm going to lose my already small number of readers if I don't post something soon. The problem is, I don't have much to say that ought to be said right now. And everything else is pretty much old news.

We had a change of R2's this weekend, and the new one is a bit disoriented by the complete turnaround in his chief's personality since they last worked together. Well, almost complete. There were still a few snarky comments here and there, but nothing overt. I can only imagine what it must have been like before. In any event, I stand by my earlier assessment that it's mostly a personality conflict.

And people have been asking me if I'm enjoying my rotation this month, as if that wasn't a foregone conclusion. I suppose they were expecting a show, given all the personalities on service right now. In fact, I wouldn't be surprised if there was an informal pool as to how many days it would take the chief to reduce me to tears. But on the contrary, for most of this month, the team has spent rounds laughing and joking with each other. And the general surgeons watch us go by, no doubt thinking "who are those people, and what have they done with the real neurosurgery residents?"

Of course, there still could be a show, but it won't happen while I'm on service. Next month, though, is going to be a whole different story. I don't see next month's intern being any kind of buffer at all. In fact, just the opposite.

The null hypothesis

I'm post-call and in a good mood today, so I'm going to share a rule of mine with you that's saved me a lot of heartache over the years. Not always, of course, but often enough.

First of all, I don't have a lot of rules about how I deal with men. But the one I have is important, and it's this: never, ever think you will be different. Whatever he's done to his previous girlfriends, you can expect it will happen to you if you get involved with him.

I have seen it happen more times than I can count. A woman finds some guy attractive, and convinces herself that he won't treat her like he's treated the women before her. And invariably, she's utterly wrong. I've fallen in the trap myself on occasion, and kicked myself later for being so stupid.

The thing is, at some point, a few of those men will get involved with a woman and not do that to her. Which is why we all hang on to the hope that we'll be that one. But statistically speaking ... no.

So what's the solution? I don't know. What I do know is that the woman shouldn't have to do the convincing on this point, either of herself that he won't do this to her, or of the man in question that she deserves better. Either it will or it won't be different, and all that can be done is to keep that in mind until the truth reveals itself. Or not get involved in the first place, which is also always an option.

Then again, using this as my basic assumption means that it takes a lot to convince me otherwise. And that's probably why I'm still single.

When you least expect it

Ever since Methodist made me choose between management and medicine seven years ago, I've felt like my life was this huge jumbled up jigsaw puzzle, with more pieces than I'd even seen yet. I couldn't make heads or tails of half the pieces, and every time I thought I had at least figured out the big picture, life would shake it up and add another boxful. And take away random pieces here and there so that the picture I was working toward no longer made sense.

But today I had a glimpse of what the current puzzle could look like, all assembled. And it's actually kind of nice. Somewhat unexpectedly, all the pieces would fit, in a way they really haven't before.

It's still a big jumble right now, though; the actual assembly has yet to be done. And the possibility still exists that another boxful could get dumped on me at any time. But this picture with these pieces ... I think I like it.

The O.C.

I went to another interview this weekend. It was my golden weekend, so the time was mine to do with as I pleased. Nonetheless, I almost didn't make it there. There was stalled tanker on I5 right at the Harborview exit (i.e. the narrowest point of the freeway), and traffic was pretty much at a standstill all the way to Northgate. Even leaving my apartment an hour and a half early, I missed the cutoff to check in by 5 minutes. Fortunately there was another flight later in the evening, which actually got me there earlier than my previous itinerary would have.

The program I interviewed at is a new one, that was just reaccredited a month ago. I was pleasantly surprised by how well-thought-out the curriculum was, and while there's really no way to tell right now which way its reputation will go, it does seem to have all the pieces in place. If they are truly able to build it according to the plan they presented to us, then I should be able to get the training I need there to become a technically competent academic neurosurgeon. I would still need to do a fellowship, as much for the additional connections as for the operative training, but I'd probably need to do that anyway.

As for living in the OC, I can take it or leave it. I was born in SoCal--in the prison town of Lompoc, as a matter of fact. Although nobody had heard of it until George Clooney was a prisoner there in Out of Sight. And really I was born in the hospital at the air force base next door, however my parents' house was on the edge of a cliff overlooking the prison. So when I need the street cred--you know, for when I'm selling my extra Sudafed to the local meth manufacturer--Lompoc it is. But I spent my childhood in Moraga, Tempe and Houston, so I'm really not a southern Cali girl at all. But I guess I could be one.

Cranial nerve I

Other female doctor: You smell nice! Vera Wang "Princess"?

Me: Nope. Bath & Body Works "Happiness"

Her: I like it. It smells very clean.

Me: Thanks.

As if I a) could afford perfume, b) would wear it at work, and c) would either buy OR wear something called "Princess". But I appreciate the compliment.

It's hard to be feminine when you wear scrubs all the time, and I'm not so girly that I would take time to put on makeup and perfume in the morning for a job where the attention it attracts is mostly a nuisance (although there are exceptions). But I have to use soap and lotion anyway, so why not something that smells nice? Also it's like a subliminal message to myself every morning: dammit, I'm happy to be here.

I'm very aware of odors in my environment. Pseudomonas, acinetobacter, DKA, EC fistulas, liver failure, errors of metabolism--they yell out their diagnosis the minute I walk in the room. Even a night of heavy drinking has a distinctive smell, particularly if the person hasn't showered that morning. It's yet another reason I like neurosurgery: very few nasty odors. Whereas general surgery has lots and lots of them. And don't even get me started on the olfactory toxicosis of OB/Gyn.

People say you shouldn't wear perfume of any kind in a professional setting. But I like to think I'm providing a service to my fellow residents by bringing a little force field of pleasant smelling air into all our patients' rooms. Also some of my fellow residents fall in that category of people who, despite showering with reasonable frequency, always smell somewhat sour.

Fortunately no one on my current service. And not that I always smell great, either, so I can't exactly be throwing stones here. I'm just sayin'.

Treating the nurses

I'm getting close to halfway through this rotation. Last night on call was probably the most painful, although educational, night so far. All my patients had issues of one sort or another, and I can't help wondering if the nurses were testing me to see if I know what I'm doing.

Back in my allied health days, the point was impressed upon me by all my teachers (both in school and on the job) that you should never call a doctor with a problem, without also providing a suggestion for solving it. The tricky part is suggesting your solution without making the doctor feel like you think you know more than s/he does. Because there are usually several ways of solving any care-related issue, and the superior attitude on your part will only encourage the doctor to think of some other way to solve it than what you're suggesting. --Usually just as legitimate, but creating more work for you than your preferred solution.

Well, some of the ICU nurses at our University Hospital are lacking such people skills. They frequently call with problems and no solution, and when they have a solution they present it more as a demand than a request. And if s/he doesn't agree, they will manipulate the system to get what they want, even if the doctor's solution was totally legitimate. My entire team, all the way up to the attending, is aware that this happens. And yet still it goes unchecked, and not just unchecked, but actively rewarded.

This happens because ICU nurses are extremely good at presenting information in a way that sounds emergent, even when it totally is not. I spent a year and some change as the pharmacist for the ortho, gen surg and CT surg ICUs, so I know that the numbers we follow to assess patients in the ICU can look terrible and mean nothing. Likewise they can look fine in a patient about to crump. Certainly we can figure out the difference ourselves, but since no doctor can be in more than one place at a time, we rely on the nurses to give us a sense of whether the numbers correlate or not, and to call us when they do.

So I wish the nurses would not cry wolf so much. It makes it harder to sort out a real emergency from the agenda-driven fake ones.

In any event, nobody died. And in fact, no one even tried to. No one was in worse shape this morning than they were yesterday morning. They just have a lot more unnecessary lines and tubes and drips and films. But the nurses feel better.

MIA: one fairy godmother

I'm bitter and cranky today. All the other general surgery residents got to go skiing, but I'm on an off-service rotation. So I had to cover while the neurosurgery residents were at their Grand Rounds, which goes on every Wednesday morning at another hospital. The ski day was originally scheduled to occur during one of my on-service rotations, which meant I would have been able to go. But it was changed a month or two ago for unknown reasons.

Theoretically I had permission to go--just as I am theoretically invited to Neurosurgery Grand Rounds--but when the work isn't reassigned as well, then in reality that means nothing. Yeah, I'm basically the red-headed step-child of both departments right now.

It's also worth noting that had my rotation been on any service other than neurosurgery, I would certainly have gone to much greater lengths to have the work reassigned so I could really go. But it wasn't so clear cut. I was also post-call and had a doctor's appointment this afternoon, so there were a lot of other obstacles as well.

I'm still cranky about it, though. It's a Gen Surg-only event, and this is the only year I'll be invited.

In other news, it's going to be kind of a challenge to work with the R2 on this service. She turns every tiny thing I don't do exactly right into this humongous indictment of my competence in front our seniors and attendings, and when I do anything independently that's correct, she takes credit for telling me to do it. I know that kind of behavior stems from insecurity, but that's crazy, because she's really good.

I'll have to figure out some way around it. The problem is, I'm only good at dealing with the insecurities of people below me. I'm not good at handling those of people above me. I know how; my mind just balks at doing so. There's that little subversive part of me that keeps saying-- if they truly deserved to be my superior, then I shouldn't have to be solving their problems. Even when there's no question in my mind that the other person knows more and is more skilled than I would be right now in their position.

It's a weakness of mine that really pisses me off. And it's also why I work well with people whom many think are arrogant: I never have to deal with their insecurites--I just have to be competent, myself. And that, I can do.

Cleaning house

I finally went back today and posted a bunch of the posts I've been sitting on from 4th year of med school. Mainly my pro and con lists for several of the neurosurgery programs where I interviewed. Also some tales from the trail, a rant or two, and a couple of posts from my OB rotation that might be enlightening. And my graduation post.

I'm still holding back a few, that I think are best left unpublished for now. I have nothing new to add from my current life, but it's definitely time to let some sunlight kill the moldy undergrowth from my 4th year of med school.

Oxymoronic

Livin' large in the PACU
Early this past week, the roof got blown off the residents' sleeping quarters at our main hospital. I don't recall it being all that windy, but nevermind. The name of the place says it all: we call it the Crow's Nest. When the residents talked about it in orientation, I remember thinking how cool it sounded. But in real life, it's drafty and cold all the time, with lights that work only when they want to and communal bathrooms. And the stairwell leading up to it smells like urine.

It was probably a pretty neat place to hang out. Fifty years ago.

In any event, the roof got blown off and all the walls got soaked through and through by the rain. As a result the residents have been assigned alternate sleeping quarters until it can be repaired. So last night I got to experience these "alternate quarters," and let me tell you: I don't care if the Crow's Nest EVER gets rebuilt. We got to sleep in the private short stay rooms in the new surgical wing of the hospital. And oh my God, that was the best night's sleep I've ever gotten in a call room! No lumpy, midget-sized mattress, no bunk bed, nobody else's pager within earshot. My own bathroom. A remote control light switch. It was awesome.

Dude, with that as my call room, I can take call all week.

Closet Full of Skeletons
The chief resident on my current service is a guy who by reputation is kind of an ass. So naturally I was a bit nervous about having to work with him. However, it hasn't been at all what I expected. I mean, I believe the stories I've heard, and he will freely admit that there are certain people he likes to torment. But what I've also seen is someone who's truly excellent at talking to patients, and explaining neurological diseases and plans and outcomes in language they can understand, in an unhurried manner and without giving too much false hope, or conversely painting too dim a picture.

On a personal level, I've actually found him very easy to work with. He used to date one of the surgery clinical pharmacists at Harborview, so he remembers most of the pharmacy crew from back when I worked there. He said he'd been wondering why I looked familiar. And the neurosurgery pharmacists at the time were friends of mine. So we spent a few minutes today chatting about pharmacy gossip from way back when. Small world.

I can't believe I'm using these two words in the same phrase, but it was actually a fun call day.

Mah mad assistin' skillz

Ahhhh! Back on neurosurgery!

It's been two days, and already I've scrubbed in on two operations. All spine, but then nearly every spine surgeon I've met has been loads of fun in the OR. There have been one or two exceptions, but by and large it's been the rule.

Today the surgeon complimented me on how well I assisted with the surgery. But it's easy to be a good assistant when you're interested in what's going on and you've seen and done enough to know how to help. Although up to this point, I've generally avoided spine cases if at all possible, so that doesn't really explain it.

I think it's just that I got some really excellent teaching on my neurosurgery sub-I's. I was fortunate to encounter a number of chiefs and seniors who were excellent surgeons themselves, and who took time to teach me how to hold and work with the various tools. I still don't know the names of all the tools--there's a bewildering array of them, and for one thing I can never keep all the Penfields straight. But I definitely feel more at home operating on the brain or spine than the abdomen.

But this whole deal with neurosurgeons being malignant personalities...I just don't get it.

Unexpected kindness

Last night was the first quiet call night I've had at Children's. All the consult calls came early, and there were no ER patients that had to be admitted to our service. Maybe it had something to do with the superbowl? I don't know, but that seems weird, since all the calls came during the game.

It's funny how small things can really make my day. Like the fact that the lady who cleans up our call rooms and makes the beds every day, put an extra pillow on the bed when she saw I was on call. And when I had gone into the supply room to get some dressing supplies, one of the nurses came in and said to me, "I know it's unprofessional to say this, but I can't believe that attending was being such a jackass. The way he was talking to you!" And then on a previous call day, the ER attending commented that I was the hardest working resident on our service. "Not that your department cares what I think," he added.

They don't, and but it's still nice to know that someone notices.

Sisyphean

I had a neurosurgery interview this week, at a program I really think is top notch. I don't know why it never makes those awful top ten lists everyone seems to obsess over. It's easily as good a program as any that do, and better than many.

The faculty and residents seemed to like me too, and most of them seemed genuine about it. But you can never really tell, and even if you could, you can't count on your assessment unless you're the last person interviewing. Which I was not.

So I googled the guy who was interviewing after me, and holy crap was that a mistake! No way are they gonna pick me over him. Oh well. Money down the drain. Back to the drawing board. If at first you don't succeed...I'm sure there's a cliche that applies.

ASBITE

I don't know what to make of that test. Halfway through, I was wishing I had busted out Costanzo's BRS Physiology to study, instead of all those stupid ABSITE review books. Seriously.

And because I'm one of those people, I checked my answers afterward. And either they were wrong in sneaky ways, or I actually got some questions right. Plus it seemed to me like the whole test was basically the same 50 questions, asked 5 different ways.

Or maybe I just totally failed it.

2007, the year that keeps on sucking

I ran across the obituary today for the mother of a college friend. He and I are not in touch anymore, but nonetheless it made me sad to see that she had died. And it brought back a host of memories. I never really knew her, but he described her as an amazing woman, who despite her own illness spent her time helping sick and poor people who couldn't do for themselves. Eshes Hayil was the term he used to describe her (from Proverbs 31, for you non-Jews). He even told me once that I reminded him of her.

So of course, I had to meet her. She was not physically imposing, but she owned her space in a way that I rarely see in women outside the field of surgery. I knew instantly that she was the kind of woman whom people don't cross. Yet there was something almost fragile about her that didn't make sense at all. I walked away with more questions than answers.

Anyway, I'm sad for my friend's loss. She died on December 31, 2007.