Taking Time to Smell the Flowers

NOT!

We move this week. A large moving van will be here Thursday morning and we're trying to get a lot accomplished in the last few days - like getting all of the kids toys and minutia over to the new place to help decrease the time it will take the movers (money saved for my program). We spent most of the weekend hauling crap over and getting it organized, taking it out of the boxes so that we can reuse them again and won't have a ton of trash at the end and so forth.

And yes, you read that right - we're staying in the area where I'm attending medical school, but I'll be a few miles away at the larger, "why are you going there - we don't like them", hospital than at the one I've toiled at and bitched about for a couple years. And yes again, a lot of the residents and faculty have a bad impression of the other place, often wondering why I wanted to go there in the first place - because they're larger, fancier, more equipped, do tons of grounds breaking research, and have a lot more money than our county hospital...and they have a residency that kicks ass. That's why.

Well anyway, we've gotten a little sidetracked here...I was just letting you know that we're turning off our internet connection and going with another once we move in. Plus with moving and stuff I'm going to be rather busy. Therefore posts are not going to be every day or every other like I've been aiming to do the last few months. Stay tuned as I'm sure I'll post a pic or two of our new place (maybe) and the white coat incendiations!

Getting It (No, not that...perv)

There were times during my last rotation where I began to understand the need to be at the hospital for extended periods even when one could leave. Not only for the training purposes - as most procedures happened later in the afternoon than earlier - but also for the overall educational quality and responsibility felt towards knowing your patient.

Interestingly, I found it remarkably unnerving to walk onto the unit the next morning after leaving the previous day. I invariably felt completely out of touch with what has happened overnight and scrambled to get the goods before rounds began. Worse still were the weekends were I had 2 straight days off and absolutely dreaded coming back in - not for the work, but entirely from the fear of not knowing what had occurred, who was there, etc, etc, etc. Part of me felt guilty at having time away from the patients I was following as though I was abandoning my role as their "physician". One woman that I covered for over a week recovered enormously overnight and was confused, but talking. We'd never held a conversation and when I went to examine her and see how she was handling the situation she asked, "Where's my doctor?" She was referring to the on-call resident, despite the fact that I was the person who knew her the best and it felt like a shot.

You weren't here, so why should I think you give a damn about me?

This was, for me, the first time that I had really ever felt guilty about leaving. It was also one of the rare times in medical school where I would find myself hanging around longer than necessary just to keep abreast of the situation. Nothing overly dramatic or anywhere near the hours my residents were putting in, but I knew that there was value to be there. I never felt more prepared for rounds and understanding my patient's situation than when I had been on call.

With my rotation officially over today, I feel good that I got a little understanding what the big concern is with residency training and hour restrictions. You learn a lot more doing than reading; and you learn a helluva lot more when you see, do, and read about a procedure, illness, condition that is presented to you in the form of a patient and follow the progression.

Now this is not saying that I completely feel that residents should go back to the insanely long hours they pulled a decade ago - I saw more than enough post-call delirium in my residents to see that sleep deprivation is scary for patient care. What I am implying, though, is that I get the dinosaur's bemoaning the current state, if only just a little more than before.

Ready to Dust Myself Off

Even though a few hours remain, I think it's safe to assume that the 65% of you who voted for me starting a new blog won't suddenly change you minds and try to sway the results. With that being said, I decided to start a new blog (for the record I find it interesting that those who felt I shouldn't start a new one were more likely to comment rather than just vote). Therefore I grabbed one under a new name that I will link with this one and vice versa.

In deciding to not keep with the God-complex/ delusion/ whatever-you-want-to-make-of-it persona I've created in the last 3 years of pathetic self-indulgence I shall be known, upon graduating May 17th, as Resident Anesthesiologist Guy (RAG)*. Cool, huh?

Now that you've had time to get over the awesomeness of this name and have picked your jaw off the floor, the blog shall be called The Chloroform Rag (get it, R.A.G.?) in reference to the infantile days of anesthesia when chloroform soaked rags were used as general anesthetics. I plan on using it as a tool to increase both awareness of anesthesia as a medical specialty as well as the process involved from being first called "Doctor" to that where it is not just a fascietious designation.

I hope that you'll make the trip to review my random postings and complaints as I finish one arduous climb only to get knocked off my high-horse into the dry and dusty dirt to begin another, harder trek.

*Actually I think RAG would work better if I where entering OB/Gyn, but whateva...

YEEOUCH

2 hours of Stepson's baseball. 1.5 hours of Daughter's T-ball. 1 hour in between. New haircut (shorter, obviously) and poor sunscreen control. You get the idea.

Note the distinctly attractive demarcation on my receding hairline where I applied the most sunscreen and where, somehow, I failed.

Almost There

In two days I'll officially be done with medical school. Oh the glory, the fame, the wonderment I see in people's eyes as I pass them.

Wait? What's that? I'm not as great as I think and my first week of internship will absolutely, no doubt about it, kick me off the top rungs of medical school heirarchy into the dregs of the lowest denominators of the hospital peasantry?!

Dammit.

But at least for now I can relax, read some, review some, and just enjoy the last moments of freedom before my life is completely taken away. Despite the generally intense nature of the ICU I've been more relaxed with issues as my time approaches. I've taken the notion that I'm still learning and really applied it to my patients, learning as much as I can from each rather than just trying to impress but not understanding what's truly going on.

Another one is the baring of arms and the tattoo concerns I've dealt with for the last 4 years. Only recently have I been more apt to wear short sleeves around peers. Now I'm frequently removing my grisled white coat in favor of bearing my arms, tats and all. This will most likely be something I shun again when residency starts, but for now I don't fear the repercussions a couple partially removed tattoos might inflict as I dispense of my cumbersome coat.

And speaking of those bastions of med school - the white coat burning is going to be kick ass! Grab a beer, throw a burger on the ol' grill, and light those short, stupid looking, monstrosities up! Pics to follow - of course.

Luxury

Hello from the one call room with a working TV! As you can see I've gotten myself comfortably aligned to view the best in television sitcoms while awaiting the page for another ICU admission. Sometimes getting to the call room early is the best - as you may not get to take a nap later in the evening.

Truth be told, though, I spent most of this time reading about HIV and metabolic alkalosis - this was a break (if you believe that).

Sex, Drugs, and...

I knew that most drug reps were full of it before I started rotations. Working in an outpatient clinic as my first exposure to real patients during 3rd year was not completely eye-opening to their ploys despite this being an first interaction with them as well. I was shocked to see, though, that the office regularly received anywhere from 3-10 a day with the majority of female reps wearing outfits that were intended to attract the eyes in “sublime” locations (some were guys dressed to the nine's who didn't exude as much sexuality as their female counterparts). Additional interest developed from observing those who would regularly purchase lunches wherein they'd give "lectures" to their captive audience. It seemed like a Hollywood cliche gone awry.

This was, in all actuality, one of the worst I've seen in the last 2 years, but variations are regularly presented - and in all specialities.

Yet, until a few days ago, I was a little murky on their education.

That was until a rotund, bleached-blonde, large-breasted woman who, while wearing an overly-tight blouse to accentuate her natural gifts of adiposity, tried to hock a statin. She began by introducing herself, her aspirations, and educational background. I can tell you that a BS in biology and an MA in liberal arts do not impress me when it comes to pharmacology and her credentials didn't extend beyond. Since I graduated with a BS in bio and could have graduated with that liberal art degree as well – damn near minored in it from a community college before deciding to go pre-med – I thought it mildly amusing that she was here to "educate".

But that’s OK – because rather than muddle her way through a memorized market campaign, she brought a video to deliver the information! A room full of residents, watching some hacky, 3-D video that was clearly marketed for the public. Embarrassing. But at least the food was good.

So now, armed with more than enough information about drug reps, I feel very little sympathy when I purposefully evade their handshakes, avert my eyes from their amply laden bosoms, phony smiles, and well-tailored suits, and eat their free lunches guilt free. All the while completely ignoring the rhetoric they spiel so blithely.

Tragic Realization

Picking through a Civil War book of which I'm quite fond I came across an atrocious image: masses of ravaged arms and legs, piled waist deep, gathering flies and rotting as a surgeon and his staff, covered in stinking, blood soaked leather and cotton aprons, began again on another poor soul.

The anesthetic being delivered came woefully from a single chloroform soaked rag and a prior heavy drink of whiskey. In the picture one of the men held the soldier’s head with that rag, covering his nose and mouth. This was the extent of anesthesia – and that being rarer as the war raged – that many a man received after having their limbs decimated by Minie balls, canon shrapnel, and grape-shot.

Surviving this extreme assault on an already destraught, damaged mind and body, the soldier faced the inevitable infection that would arise and hope, praying pitifully, that God would spare their lives. Many prayers were not answered and thousands died from postop complications.

We’ve made leaps and bounds in 140 years, people. As much as people don't understand anesthesia, I'm sure they're grateful that they don't have to undergo such horrors.

What Savior?

Where will all of the primary doctors come from? Serious question – not rhetorical. Despite the assuagements from various people that the PCP is and will be filled by foreign medical graduates who’ll be more than happy to work in rural environments, I’m concerned.

For instance, many of the senior foreign residents in the Medicine program at my hospital are talking about taking hospitalist jobs when they finish. I’ve yet to hear one who has discussed going into private practice.

Not one.

And why is that? Because docs are greedy, money-grubbing, unethical whores, worshipping the almighty dollar in a gluttonous orgy of padding profits and ordering unncessary exams while Rome burns (or something)? Or is it because the government, that same government that plans on swooping in and “saving” American healthcare, is actually the etiology behind all of this?

Think about it. Medicare is the main stimulus for insurance reimbursements for everything from major to minor insurance companies. “Do as I’m doing, follow, follow, me” should be the mantra of Medicare as they cut payments and dare docs to retaliate. Private insurance companies take heed, and follow similar cut backs in payment - rather than acknowledging that their reimbursement schedules are messed up.

So congress, rather than being smart about cost-effectiveness, believes that in order to balance their budgets (oxymoronic term if ever there was) they have to pay hard working doctors – who've spent more than a decade getting an education – less and less. We're now seeing the deliterious effects that years of this foolhardy maneuvering has caused; removing office-based, primary care out of resident’s minds.

Further insult comes from beauracratic nonsense that, while not completely government controlled, is basically just a few votes shy of becoming part of the FDA or some other monolithic entity. Of course I’m speaking of the idiocy known as JCAHO and all of the ridiculous limits and strangleholds they place on patient care disguised as “safety measures” which only leaves the physician spending hours digging through minutia and dead-ends in order to "meet standards".

Bullshit.

Yet, millions of Americans are being dupped into believing that they must have universal coverage in order to get healthcare – and they’re buying it hook, line, and sinker. It has taken center stage over most every other consideration during the recent campaign speeches. The economy? Iraq? Ha, mere annoyances compared to this impending "disaster".

It infuriates me to see people who are highly qualified physicians avoiding the work that their residency was initially designed towards. I don’t bemoan them. Hell, I’d being doing the same thing. What I find sickening is the idea that the government will fix this. That the good ol’ US of A can be saved by lawyers and career politicians who know as much about medicine as they’re able to maintain party neutrality and an open mind. Ha.

Junior Mints

Hrrm.

Watching 3rd years brings back memories of surgery clerkship – walking around in groups, thinking you’re a bad ass while the residents do everything, and not knowing what the hell you’re doing but acting like you do – yeah, I remember those days well.

I’m still living them.

But in all seriousness, the juniors have been putting in some serious work this week. Many of the ICU patients are surgical, sicker than snot, and require a lot of interventions/ management/ follow up, leaving the juniors arriving throughout the day trying to find some data that's needed. Most are here well past 6 pm on a regular basis.

Yet, despite these hours and the conditions they've been launched into in the last 1.5 weeks, I still can’t fathom why anyone would walk into a patient’s room whose on contact precautions, touch them with their bare hands, and get huffy at the nurse who tries to stop you. I get that you’re tired, man, but is the extra few minutes of putting on a cover and gloves really worth risking infection? Plus snapping at the nurse will only get you on a shit list that you don’t want to be on. Trust me.

Overall though, the thing that bothers me the most about them (not that they bother me in and of themselves) is the fact that they have to change into nice clothes as soon as they leave the OR. One girl had to leave and change before she could help out with a chest tube the other day (which was subsequently completed while she was gone). It floored me.

Gone are the days of walking around in scrubs – like I was allowed – and being able to deal with the fluids and contaminates since you could just get another clean pair from the OR. That was one of the great things about the surgery clerkship – not having to wear a tie and iron your damn clothes or worry about destroying them.

And there were great days on that clerkship. But I mean, do you really have to avoid wearing the scrubs altogether? The residents still walk around in theirs, why can' t the students?

Question Y'all

I've been toying with a few ideas for when residency begins as to what to do with this blog. I began it as a memoir of medical school and a place to vent frustrations during those times. I wish I still had my posts before the "delete" incident, but they're gone and there's nothing I can do about that - so let's not worry.

Instead what I've been pondering is whether to keep writing on this forum (since many of you have come to know MSG without the full name being spelled out) or keep it linked, but start anew - fresh and free from my monicker's shackles.

After all, I've several posts under the title of Medstudentgod and I honestly don't want to have an archive list a mile long dealing with med school and then residency. Perhaps it's time to get a new blog, to chronicle the next phase in my journey. Who knows.

So, I'm asking...should I keep writing on this forum, or start a new blog; a template that's clean from all the hate and bitterness that encompasses much of the posts herein. I've added a poll for the next couple weeks. Please let me know. I value your input.

Do You Have This View?

Even though call sucks - mostly because I can't do much and sit on my hands all damn night long, waiting for something to do, ergo the 2 posts in one day!- I have to revel at the beauty I'm awarded from my call room's window on the 9th floor as twilight descends.

Taken from my cell-phone, so it's not the best pic, but this encompasses the older parts of the hospital, the dental school (building on the far upper left), and a portion of a university that is across the street (not affiliated with us). It is far more breath taking than this crappy shot demonstrates - trust me.

Reading Rainbow

So I hinted earlier about my uptake in pleasurable activities during this semester and the slip in my medical knowledge because of it. I was thinking about the amount of literature that I’ve read through and, while not epic in any sense, it is rather astonishing to regard the amount of reading I’ve undertaken in the last 6 weeks. My list of fiction that I’ve gulped down with child-like glee includes:

1) Cutting Remarks by Dr. Sid Schwab
2) Odd Thomas by Dean Koontz
3) The Face by Dean Koontz
4) False Memory by Dean Koontz
5) The Shining by Stephen King
6) ‘Salem’s Lot by Stephen King
7) Nobody True by James herbert
8) Mary Shelley’s Frankenstein
9) The Killer Angels by Michael Shaara
10) First, Do No Harm by Dr. Derrick Beech

Most of these have been excellent reads, but it staggers the mind to think how much time I’ve spent absorbing fiction. No wonder I’ve gotten a little rusty. Up next? Carrie.

Respect II

Overheard while performing the babysitting duty:


Nurse 1: "They went and ordered for [some test] on your patient".


Nurse 2: "Well, I told them that they needed to get that test...3 DAYS AGO!"


Nurse 1: "I guess they didn't feel it was needed at the time?"


Nurse 2: "Who knows what these docs are thinking? But, whateva...I'm just a lowly nurse anyway...don't know shit."


Nurse 3: "Who ever said you knew anything to begin with?"


Nurse 2: "Shut up, bitch!"


They then all proceeded to start laughing hysterically. I didn't get the joke, but the innuendo from the critical care nurses that they know more about how to take care of patients than the doctors (surgical, medical, attending, resident, or otherwise) is more than covertly spoken. But only when the docs aren't around - I apparently don't count.

Respect

A note from the ICU in which the impression on the residents and attendings is clearly manifest. Sometimes you just have to laugh. I personally enjoyed the grammatical errors that are rampant throughout.

Death Rattled

A face to face encounter with death is something not normally undertaken by most people. I’ve begun to see enough of the haggard face of Death that I’m getting slightly immune – slightly, not completely.

It used to transfix me, watching someone die – especially in the ICU where so much seemed to be happening. Now I go about my business, still checking in to see if Death, with his icy, skeletal fingers, has deposed a soul of their body, but I no longer hang around and wait.

Gasping for breaths, eyes lolling absently within the skull, chest and abdomen heaving from the physiological desire to increase the body's blood-oxygen - not normally a pleasant view to observe. I think I’ve seen enough to remain interested, but not morbidly fascinated - as if I'm witnessing my own mortality through another life’s culmination.

I do know that the exposure has solidified any unnecessary desire in me to seek heroic interventions for own life. Do what you can, without going overboard - that's my take on it. These people who spend days to weeks in the hospital are, for the most part, already door nails (if you get my drift) – we just fool ourselves while the machine works.

To further these considerations I have decided that I should attend an autopsy - offered at certain times for those students/ nurses interested to which I was heretofore unawares - while on this rotation to finally deal with Death's throes over life. Seeing the completeness of a body emptied, lifeless, being quickly but systematically cut open in an attempt to understand the "flawed defect" that resulted in death should be riveting. And an experience that teaches how fragile life is - in spite of our societal denial that death is the inevitability of life.

The Sitter

Today I figured I'd cury some favor from the nurses and spent about 2-3 hours babysitting a patient. They were there for several days while we attempted valiantly to wean them off some sedatives and get them up to the floors secondary to severe alcohol abuse. Unfortunately there were an infinite number of sick patients (it is the ICU after all) and the nurses had not been able to keep their attention on this patient when they were out of bed – so they sedated more and kept asking for restraint orders. It's easier if they can't move, ain't it?

Finally today the attending asked for us to take shifts and watch. And since they were mine, I took first shift – which showed a very coachable, easily manageable patient who needed to get the hell out of the ICU and go to the floor.

I try to not think about the cost to me in dollars for an education where I babysit patients, but then again, I had nothing else to be doing at that time anyway. I should appreciate these times more. Plus I looked good in the eyes of the nursing staff - which will mean that they'll watch out for me for the next couple weeks - hopefully.

News From the Front

Medical students are useless. We just are - adding extra work to resident's daily to do lists, getting in the way during procedures and rounds, and having to be accounted for on a regular basis all leads to a rather mundane and useless person.

Yet for all the tomfoolery that goes on with training med students the majority of residents/ attendings/ nurses are nice and considerate to make you not feel completely ridiculous. Most. A nurse from the L&D ward was down in the ICU yesterday and she brought with her the mentality that I hated on that floor: get out of my way you useless piece of shit!

Twice I was attacked by her for just looking in a patient's chart (which I had to defend by stating it was my patient, so back off), I witnessed her badger the radiology tech for HIPPA violations since she was walking around with patient labels on her sleeves (which most people do when they're actually, you know, up and moving to get their work done and not sitting behind a PC all day), and several times this behemoth of a woman got after the residents. Once she even went so far as to tell my senior "You need to get off my computer and get back onto yours!" The resident yielded, laughing outwardly at the farce this woman was making of her position, and I smiled as the nurse pulled up her important work - shoe shopping online.

Good Times

It’s nice to find out that you’re going to have a moving company work on moving you from a 3rd floor apartment into a home with stairs and a fairly steep driveway – all paid for by your program.

It’s wonderful to have signed on a home and know where you’ll be living for the next few years.

It’s fun to roll in the grass with my kids, despite the dangers of doggy poop landmines.

It’s exciting to complete items needed by your residency program – it makes it seem like you’re already there.

It’s fun to have sloppy joes for dinner when everyone is tired but starving. It reminds you of how simple life actually is and how complicated we tend to want to make it.

Lessons

My considerations regarding the embarassment I felt during a pimp session have ultimately led to an inevitable truth: I should have known this material.

Whether it resulted from my not reading as much as necessary (I had been reading about this the night before, but fell asleep with my CMDT lying fitfully on my stomach and didn't get it in the ol' brain) or the reduction in patient and floor-type care contact, I don't know. I believe, however, that the atrophy of my knowledge was a direct result of various interactions.

For one, I have not had to deal with heart care in more than a year except in the OR - where the care is decidely more acute, with different drugs and algorithms being employed. In fact, I, along with hundreds of 4th years, haven't had much to do with medicine at all in many months. No matter how much you read something, if you're not involved to some degree beyond printed text you get stale.

Another factor is that I have been taking some time for leisure: reading fiction, music, working out, etc. Medicine has been at a back burner for a few weeks and it's hard to dust off the cobwebs sometimes.

Yet, in this humiliating and seemingly frustrating week I've learned something profound that has, until now, not been fully realized: You need residency training to become a doctor. Simple, right? But it's often so easy to think that we're coasting, doing well, and that residency is too hard and too long just to get a little ahead of where you're at now, so why do we really need it? Then you have moments like this and think "Not so" - the nature of trying to do something, failing, being called out, and then going over the scenario and reading about the current treatments helps create an impression in your brain that wasn't there before and would never have existed except through experience. And that's what it's all about.

Suck

Today was not a good day. I've forgotten a lot of floor patient management and certain things have just leaked out of my brain - leaving me helpless in front of pimp happy critical care docs. When the resident looks at you and tells you that, as a 4th year, you should know that in and out you feel like dragging your beat-down ass out of the ICU - you've no business being there.

Tired

Just got home from being on call. I'd forgotten how tiring this process can be, even with 4 hours of solid sleep. The hospital wears me out...plus trying to find a bed when the previous med student call rooms were completely full/ locked/ or under repairs didn't add to the fun.

I don't know what is about being on call that makes you eat horribly, but about 9pm I began craving like mad and broke down, getting some serious candy munching - only to regret it.

Stoked

Psych note: Patient noted to be in chain stoking respirations. Ah, yes, stoking the chain while breathing - classic.

Just Had to Say It

It actually irritated me a little that someone would, anonymously – like a troll, suggest that I was second guessing my choice for residency. In part because they completely missed what I was trying to write about, but more from the idea that I was having some kind of reaction formation about choosing anesthesia over surgery.

I made the decision early in 4th year. Up to that point it wasn’t that clear – since I’d only ever had very minute experiences with anesthesia, but had multiple and impressionably profound moments of surgery throughout the previous 3 years. It’s always easier to believe that you’re fit for something when you get more knowledge about a field – plain and simple. Once I had a month of anesthesia under me my choice was not that hard.

But it is true that I also made the choice based on a desire to be with my family. An desire that didn't seem as feasible the more I was able to perceive resident and attending surgeons doing very little with their kids and spending countless hours at the hospital. Yet someone feels that I am trying to create a negative attitude about surgery simply to remind myself why anesthesia was the better choice. I tried to ignore this absurdity for a time, but it’s just gotten under my skin and I feel the need to just say "fuck off"! And that’s enough about that topic.

****

On a different note – I have realized that I will suck starting July 1st. Two days in the ICU have taught me that I unquestionably know dick. 4 years of med school and I still suck my thumb when confronted with sick-as-hell patients.