Enigmatic

During a recent discourse on end-of-life care I realized that anesthesia is a very misunderstood specialty. Basically a topic about drug-induced comatosed patients turned to various items related to anesthesia - like paralyzing medications, propofol induced comas, and the need for pain control these situtations.

What I found interesting was that the physician, with many years of experience dealing with dying patients and ICUs, didn't really know a great deal about an anesthestic state produced when one creates a drug coma. He didn't remember what drugs were used to cause muscular paralysis either. A couple students trying to be helpful shouted out succinylcholine.

"Well, yes, that does cause paralysis", I thought, "but for a very limited time (2-10 minutes)". More likely he was referring to the longer acting non-depolarizing muscular antagonist - like vecuronium or even pancuronium (since we're talking about dying ICU patients here). But no one brought these up. Multiple suggestions of a depolarizing blocker, but nothing else. A lot of places don't even use sux anymore because of the side effects, but I'm going off on a tangent here.

He then went on to discuss whether pain meds were needed in these types of comatose patients. What amazed me was that he wasn't sure if they needed them or not. Some of my peers suggested that propofol was useful to prevent pain. Hm, news to me. I thought that opiates and other painkillers were used for this, but maybe, again, they were thinking back on their surgery sub-I and remembered the anesthesiologist giving some propofol when a patient was "awake" and moving - thus the belief that it affects pain. I wanted to talk about the fact that people do respond to pain even when in drug comas, and often anesthesiologists titrate opiates and other pain relievers in based on physiological parameters, but decided it wasn't worth it.

Ultimately I found it interesting that the nature of anesthesia is so misunderstood by many people. "Give some white stuff. Pass some gas. What's so hard about that?" Apparently a helluva lot more than you'd think - since most people involved in care that mimicks anesthesia's induction and maintenance have false notions on what's going on. I don't want to know what a surgeon thinks - I'm sure it's even more basic than that.

Trust in Pain

A comment recently received caught my attention. And not so for it’s questioning of my patient attitudeness, but more for this first portion:

I think it is interesting that you have chosen anesthesia as your specialty - the management of pain issues being one of the few areas of medicine where the physician has to simply trust the patient to report their pain since there is no objective test to prove it. Have you thought about how you will manage when a patient reports pain (and i'm not speaking of one of the flat out easy to spot drug seekers) but you feel you have treated them adequately? If you, using your prior experience and all of your knowledge don't feel they need more meds despite what they are telling you - what will you do?

Fortunately I received a great lecture on this topic early in my 3rd year that has stuck with me. Yes, there are those people out there who abuse the system and want to have narcs up the wazoo just because they want to get high. However, in anesthesia we do have to be more receptive to the idea that someone’s pain is a 10/10 even though they are sleepy.

The lecture to which I referred earlier was by a doctor who worked with the old and terminally ill. She often gave dosages of pain killers that many other doctors thought would surely kill the patient. Her advice was that pain should never be uncontrolled just to remain within the “standards” of the pharmacopeia.

“The patient will let you know when they’ve received enough. You just titrate out the amount until they are pain free or close to sleep. Then you’re at your boundary.”

In most patient encounters this wouldn’t work too well – not enough staff to watch carefully over the patient as the drugs reach their peak effect. However, in the PACU, where we have nurses who carefully observe and manage patients, we can adjust more readily. They are given orders for pain management by the anesthesiologist, who, by way of observing the patient’s narcotic need intraoperatively, will have a better understanding of how tolerant or labile the patient is towards pain control measures. These can then be adjusted based on pain scales and overall patient physical characteristics.

Addressing the notion that we lack objective tests, certainly during the operation there are physiological parameters that anesthesiologists look for when controlling pain: increases in blood pressure, heart rate, breathing, perspiration, etc. are all items that alert them to a need for increased pain management (this being said, it is important to realize that even though the “body” is responding by reflexive physiological measures, the patient very rarely has any recall). This is a form of acute pain control, often a direct result of a noxious stimulus. Many patients present with similar findings, even when conscious, and allow for more visual confirmation of pain. While easier to understand and treat, we still have people with chronic pain, vague and mysterious, that's often at the heart of these controversies between physician and patient.

Rather than label a patient as a "malingerer" or "druggie" who presents multiple times for low back pain, neuropathic pain, or "flares" we must trust them. And that’s were the catch comes. That’s were so many healthcare providers, who entered medicine wanting to help only to be burned time and again, are now skeptical of most pain complaints. The abuse they've seen and endured, at the hands of addicts and malingerers, hurts more than just the patient - we all suffer to some degree.

Considering the notion that people report pain even after receiving large amounts of highly potent narcotics, you can easily expect providers to write the patient off as an addict. Unfortunately, while true in many cases, some pain cannot be well controlled with medications or is completely untouchable. This leaves the sufferer searching for assistance, help, and relief from the constant agony. Pain specialists are often useful for these kinds of patients, using advanced pain management, through invasive procedures, to help in these cases. A rather lucrative field, I personally have no desire to entertain such thoughts, as pain patients are some of the hardest people to treat, having been "mistreated" so many times.

Many forms of pain are hard to diagnose, treat, or even moderately control regardless of level of therapy. Asking for a quantification (the best known is the 0-10 scale) is often hard to deem accurate as pain is patient specific, based on psychological, emotional, and environmental cues. Someone claiming 10/10 pain may actually have the worst pain they've ever experienced. Just because we've seen people in worse situations shouldn't cause us to feel they're lying to us - it's completely subjective.

A theory postulated by some neurologists and others has suggested that the brain “makes up” pain in order to elicit stress responses that were once normally found – we’ve just become too comfortable and it’s a fall-back mechanism gone awry, kind of like the increased incidence of allergies. I kinda like that idea and understand it – after all, many of the harder to “trust” diseases like Fibromyalgia are more receptive towards medications targeting brain chemistry and function*. Whether I believe it to be a real disease is not the question, the patient believes it and therefore they suffer from it. We need to understand that more.

I honestly feel that we must listen to a patient and assess them truthfully while at the same time the patient must also listen and adhere to physician advice. An overdose of pain medications results in decreases in many aspects important for body funtions, including breathing and cerebral consciousness. If patients are found to be sleepy, lethargic, hard to arouse, disoriented, or having some trouble breathing at a normal rate they shouldn’t receive anything more - regardless of additional complaints. That's were the education comes into play. The physician must acknowledge the limit and be in control of the situation, without allowing emotions or a concern for legal action to influence their decision.

Despite the fact that there is some evidence that pain exists regardless of conscious level (i.e a sleepy patient can still have 7/10 pain) we need to accept that the limits have been met or breached and inform the patient as best as possible. I might still trust that the patient has pain, but my ability to help with more narcotics has been limited. My hands are tied.

*Is it just me, or do those commercials have the crazy patient look down? I look at those ladies, talking about their pain, and just shudder.

Low On Gas

Recently I took some of that golden free time over the holiday to try and drum up some more “MSG Worthy” blogs. Not that I’m all powerful and everyone bows down to my suggested readings located to the left. In fact, it would seem that no one pays particularly much attention to me anyway (as my siteviewer indicates an increasing drop in visitors), so it’s merely more of a “favs” for me when I'm away from my traditional PC. Now you get it – yes?

Anyway, I found that I had a rather hard time finding Anesthesia related blogs. I was fortunate in being able to find a couple that I enjoyed perusing and, even more fortunately, they also had a couple links here and there of other blogs written by Anesthesiologists that for one reason or another were relegated to "look at later".

But I’m concerned…just 3 blogs overall that I found worthy of being placed on my “read regularly” list? Where are all of the great Anesthesia bloggers? I know they have stories – just like surgeons – and are a great deal more well rounded than their said counterpart. Humour, intelligence, and personality abound in anesthesia, so why so few?

I tend to consider the nature of the job when I ask this question. I also find that most people really have absolutely no idea what it is to deliver anesthesia which, possibly, leads to a great deal of frustration. I mean, how many times have I read in Michelle Au’s blog a comment here or there where some commenter says something like: “Yeah, but you were like, a REAL doctor today!"? Far too often, I'm afraid.

I see these, read them again, and think: "WTF? Real doctor? Idiot".

Anesthesiologists are more than just technicians, but most people honestly believe we just put you to sleep and leave the room. Even amongst those we work with regularly I see an amount of ignorance - even if they do hold a great deal of respect for their colleagues - that I just don't understand.

Fortunately I'm hearing that more surgical interns are rotating through anesthesia for a month or two in order to gain a fuller appreciation of the nature of perioperative medicine and it's strengths/ pitfalls before they're too hardened. On top of that more anesthesiologists are also branching out into critical care medicine and other medical fields where the true nature of perioperative medicine can be utilized...maybe we really can all get along.

Perhaps it is the lack of understanding, even amongst our co-workers, that's the causation behind the diminished interest in the anesthesia field to author a weblog or, for that matter, in the reader to actively search out the “Gasman”. Surgeons and ER docs seem to hold a great deal of notoriety as the coolest docs out there and therefore seem to have more opportunity to capture an audience (look at Medblog Addicts "Calendar Docs" on her sidebar and you'll see what I'm talking about). Who cares about the guy who "watches the surgeon work"?

I guess that as I progress in residency I’ll loose a lot more readership since I'm entering a less than cool field (to you, not me), but at least I’ll be another voice in a specialty that doesn’t receive nearly enough acknowledgement or praise.

Attitudes: Surgeon and Anesthesiologist

Let me preface this post by saying I have a great deal of respect for surgeons and anesthesiologists. I entertained thoughts about both specialties and believe I would have made a great surgeon, but having decided to go to the other side of the blood-brain-barrier I have to make some effort to respond to these comments seen over at Dino's blog:

Hey you want that lab, you order it and deal with the result before you screw up the surgery schedule for everyone including the patient! I wonder how many anesthesiologist's are only children (I had to reply to this comment with the surgeon temper tantrum - children indeed)?

To this day I remain dumbfounded at how an anesthesiologist can walk into a room cold, review some pertinent facts on a patient and decide that administration of anesthesia won't be problem.

Having done a couple anesthesia months allowed me to see a little into the surgeon-anesthesiologist contest that constantly occurs, often behind the smoke and mirrors of surgical holding areas where patients sit anxiously awaiting. Most patients probably don’t even think about the anesthesiologist until they meet them right before they head back for surgery. Their surgeon is often the only doctor that they’ll remember from the entire event – unless something goes wrong and they try to sue everyone – but they don’t realize that the interplay between their surgery happening and staying alive during the case is often held in the hands of the “Gasman” and not the surgeon.

You see the anesthesiologist is often considered the “internist of the OR”. They check out patients the night before if they’re inpatients or review their history prior to the first meeting in order to optimize their anesthetic plan. This is done in order to understand what direction to take, what drugs to be wary of, whether another induction agent should be used over “white magic”, the medical illnesses a patient has that might need more attention in the OR, or if there are conditions that need to be evaluated further prior to anesthesia being delivered.

They are responsible for keeping the patient alive, not the surgeon (despite surgeons notoriety for saving people’s lives), and there are sometimes tests that have to be performed or evaluations done before surgery can commence to reduce morbidity or mortality. The problem that many surgeons have, at least from what I’ve seen, is the seemingly arbitrary demands that an anesthesiologist may have for a patient evaluation.

Well, it's a little more complicated than these two surgeons assume. Let's consider a 35 year old patient who is scheduled for an elective procedure related to gallstones. In the H&P the surgeon notes a congenital abnormality of the spine, but does not follow up more. The anesthesiologist reviews the abnormality the night before when they receive their case assignments, realizes that the location involves the cervical spine with potential for disasterous outcomes during intubation, and sees that the last check on the C-spine was over 2 years ago.

Had an anesthesiologist been able to see the patient in their preop clinic they could have anticipated the demand more than a surgeon concerned more about the chole and had a C-spine evaluation performed. However, because this outpatient surgery center or hospital doesn't require this before surgery the anesthesiologist often times only has the night before to be even aware of the cases scheduled and must attempt to obtain labs and other tests the day of surgery. The surgeon, however, sees only a delay and the lazy gasman as the cause.

This situation can be extremely frustrating to all involved, with the surgeon wondering how anyone can cancel or delay a case when only “seeing the patient for the first time and only for 5 minutes”, the patient is upset, hungry, and bewildered as to the delay, and the anesthesiologist wonders why in the hell this patient wasn’t properly preop’d as he's scapegoated by all involved.
Some surgeons call anesthesiologists lazy bums because of the belief that they sit and read or simply “watch the surgeon work”. There are some surgeons who believe, honestly, that they can administer anesthetics and operate at the same time. What they don’t understand is the fact that if it appears this way, then the anesthesiologist is doing their job well.

A patient who is tolerating anesthesia and has a rather stable operations is not just an everyday occurrence as many people believe – it requires diligence, understanding of complex physiology and pharmacology, and the training to maneuver through complications seemingly with ease. Just as an anesthesiologist shouldn't pretend to know how to perform surgery a surgeon shouldn't assume they know how to deliver anesthesia.

I’ve seen it go bad, though, when the patient crashes, things are going wrong, and the surgeons look wide-eyed as the anesthesiologist attempts to combat the grip of the reaper - sometimes after a completely uneventful operation. At these times the surgeons may offer advice, but more often than not they stand back and watch. Many times these events were unexpected, but occasionally there are hints that were overlooked in the original H&P that could have steered the anesthesiologist on a different course to avoid complications.

This has lead some hospitals to require preop evaluations by both the surgeon and anesthesiologist, since they often have differing needs and questions prior to surgery and this maximizes good outcomes. However, at least at the academic settings I've been involved, the cases are not listed until the late afternoon or early evening, are subject to change and add-ons, and often leave the anesthesiologist in the dark if the patient didn't get an anesthestic evaluation.

Of course both fields are necessary for surgery to take place and it would behoove all involved that the two fields work together. Yet, more often than not, surgeons consider anesthesiologists as part of their OR team, and therefore beneath them while some anesthesiologists refuse to cater to this demeaning attitude and believe that they are the primary since they manage the patient while the surgeon “fixes a problem”. Both lines of thought are, of course, erroneous, but continue to persist.

What I have seen, though, is that there are residents in anesthesia who jumped ship from other specialties. Often times a surgical intern or second year resident realizes their folly in entering surgery and comes to the other side. More often than not I saw people coming to anesthesia rather than abandoning it for greener fields which speaks volumes of a specialty. I actually think that there's a lot of bitterness on the surgeons part - for whatever reasons - that leads to some of their attitudes.

The reason for writing this, in part and beyond the comments read at Dino's, is because of a couple of my friends stuck to general surgery as their residency of choice while I went another way. Sometimes they’ll poke fun at my decision with the occasional “did the patient get antibiotics?” or “table up, please!” commands while we're hanging out. I often will reply “I’ll do it when I’m damn good and ready!" or "whatever, you don’t order me around!” Of course this is all done in fun, but hopefully this isn’t a sign for our attitudes later in our careers – that would be just sad.

Interview Dribble and Random Thoughts

I recently cancelled some interviews. I was giving the dates that I’d be out to Wife in order for her to adjust her schedule for work and she began to freak. Six different dates in December, her biggest month and also the time of year when she has to work overnight per company guidelines, were just too much for her. I looked at the interviews, realized that I had one every Tuesday and Friday with dinners the night before during the next 3 weeks, some with 3 days of travel (flight cheaper that way), and analyzed my options.

I cancelled those that I could – those that weren’t as high on my list already or didn’t have a nonrefundable flight attached to them. If I hadn’t worried about rising gas prices a month ago I would have gone to a Texas program over one in Pennsylvania that I've already purchased a ticket for, but I’m stuck now.

For a pre-birthday gift Wife purchased me a Magellan Maestro GPS unit to help navigate during this time. Since I’m driving to a large amount of these programs it helps to have something that can get me around town and this is a great gift! I used it a lot this last week just to see how it works, going to places I knew how to get to already, but seeing where it would take me and if there were any problems. Dead-on every time and it worked quickly most of the time. A few times it stalled getting my information, but during the trips it was fantastic.

Getting an idea from GruntDoc, MD, I decided to do a dead blog update of my own. Basically if there hasn't been any activity for 2 months I deleted you from my sidebar. Those considered dead are:

• Adventures in Medical School
• Parcho, MD (let me know if you start again)
• Scutmonkey (went private)

So, being in an after turkey-day malaise, tomorrow I plan to get out the Christmas decorations, start to get the tree put together, study for my Step 2 CS in a week, and eat a lot of leftovers. On Sunday interviews begin - oh yeah.

Getting Back To Basics

So here’s the thing. I like writing posts where I know there might be some reaction. I like checking the comments to see who’s upset or what agreement, if any, there is amongst my few readers. It’s fun.

The last post was for me, but also for that simplistic pleasure. That’s part of the reason the heat gets going as a post continues– to get a rise out of you. Unfortunately I may have caused some of my med school buds to feel I don’t support starting a family while in school. Simply put – I completely support anyone who can juggle this craziness with kids. I don’t have any qualms about women having children during residency or afterwards either. My beef was not with med students taking time to have children or their need to have accomodations afterwards. My beef was with the student in question only - because she sued. What does that say about her? That was my point.

So, that’s that. If you’re still upset or irked then there’s nothing I can do. It’s my blog and I write what I want.

Anyways, the Tassimo poll has completed and basically more people have no idea what Tassimo coffee is than those who either love it or hate it (which tied BTW). No idea where to go with this information, but at least I know that I'm not the only one who loves it...

…and I’m looking at my veins as I type this dreaming about sticking large bore IV’s in those juicy ass rivers of blood. Part of wanting to be an Anesthesiologist I guess. 2 days from my first interview and I'm wondering why all of this is necessary. $4,000 in travel expense thus far without hotels for most trips - yet. Damn.

A Decision

I’ve decided to drop my last Anesthesia elective. My reasons are multiple and varied, but mostly hinge on the concept that I honestly think I’m fucking myself here.

I don’t feel I’ve done badly, in fact I feel I've been quite on point, but I honestly don’t have a clue. There’s nothing to compare my performance with other than the various medical students wandering around who, at one time or another, appear vastly superior to me and vice versa.

Some days are great – IV’s are easy, intubations a breeze, and the patient does well while I bond with the resident. Other days I get nothing right, get yanked out of a CRNA’s room to avoid her bitchiness about me "jumping on" her case, and seem to be put in the most absurd rooms where I can do absolutely nothing but sit there and stare at the EKG rhythms while important matters are attended to.

It’s been fun, but I’m scared about doing two electives in programs that I feel I’ll rank high. It’s just not been what I thought it would and it worries me. I have a good application and feel I will get interviews from most of the programs I've applied to regardless of "showing them my stuff". I feel that I could be hurting my chances here if one person thinks I'm not good for the program. It's a huge gamble.

Aside from all of that, I've also been told that most of the people I've worked with don't have anything to do with residency decisions, and even if they did they don't remember med students very well - because there's so many between now and February. So what's the point in making it harder for myself?

So, I now have to rearrange my schedule when I get back in a little over a week to fill in that month. Hopefully that won’t be hard to do.

Hi There

Hello from the busy world of Sub-I! Yes, I decided to let you know about the week I’ve had (short form of course) and that I’m still alive.

I’ll tell you right now that if you’re unaware of how taxing it is to be "on" all the time you have got to put yourself somewhere for a day and try it. It drains you. It sucks the energy out of you as you try to read, look busy, appear genuine while all-the-while kissing ass, and simply going above and beyond everything you’ve ever done in order to meet expectations.

It’s hard.

Saturday was a day off and I found myself completely asleep till 8:30am. That’s early you say? Considering I’ve become accustomed to the 4 or 5 am awakenings with work, Wife, and Daughter, anytime after 7am is really late. Really late.

It’s been very interesting and fun, however, and I’ve honestly enjoyed the faculty and residents tremendously. I find myself hoping for acceptance by their institution. It’s a great place and most of the residents are very keen on the teaching environment and have been quite friendly. My IV skills are being tested constantly and my intubation success has decreased a little based on the degree of complexity I’m seeing in these patients. Thursday I go to see my first neurosurgery case ever – it was hard to consider what needed to be done, but the resident was more than ready. Needless to say, it impressed me to see how well trained this CA-2 was.

Also I've lost my contacts (one was lost after falling out of my eye - in a case nonetheless!) and I purchased some glasses. I plan on getting some contacts again, but right now the glasses are fine and are more applicable to the OR environment anyway.

***

Today I submitted my application to ERAS (electronic residency application service) for the hefty sum of $270! Apparently I was charged separately because I was applying to 3 different types of programs (Anes, prelim IM, and Transitional Year) despite my dean assuring me that this wouldn’t happen. Hmm, my school’s not got the most accurate information? Who knew?
Anyway, I’m glad to be where I am right now, getting the ERAS crap over with, and can now look forward to accepting interviews – hopefully.

Working It

I may be MIA for a while - in fact a month or so - starting today. I've got my away rotation in my 2nd choice for residency (at least at the moment) that begins Monday. I want to be impressive and need to study a lot. Plus there's probably not going to be a lot of places where I'll be able to blog since where I'm staying only has dial up and I'm not for waiting hours on end just to update.

So, with that being said...enjoy the archives and check back every now and then for the impromptu update.

Also wish me luck. I feel I might need it.

Impressive. Most Impressive

I’ve had the "pleasure" of being harassed in the OR by a couple surgeons who feel I’m “wasting my natural talent with Anesthesia” or that I’ve “gone to the dark side” of the curtain. I’ve also received similar remarks from other physicians in Internal Med and Family Med when asked what field I decided to enter.

In some ways it feels good that a reaction such as this is generated when people find out that I’m not pursuing their field. It means that they felt I might have made a good cutter or were desirous for me to pursue a residency and become their colleague. I was wanted.

What is upsetting, however, is the underlying insult that Anesthesiology is a weaker field. Whatever the reason (perhaps seeing people getting to eat and sit while surgeons starve and stand for hours on end has something to do with it) Anesthesia is an exciting field that is very misunderstood. I understand this to some degree and have begun to accept the fact that others will always consider me a lesser doctor (hell, part of my personal statement discusses this very thing).

Despite this, however, I’ve taken these comments (backhanded though some might be) and thanked the surgeon, Internist, Family doc, etc. for their praise. Because that’s what it is – praise for a job well done over last year. I’m grateful for it, in whatever form it takes, and will hope to only continue to impress as I continue my career.

Now I just have to grow thicker skin…

Not So Cool Anymore

So I’m starting to understand why surgeons have such a bad name amongst hospital types. When I was rotating on Surgery I thought it very cool to be the macho, gun-slinging, cowboy who marches into “their” OR, orders what needs to be done for the patient, and takes control. After all, this is their patient and clearly no one has learned as much as the surgeon. Everyone else is inferior.

However…

Being on Anesthesia and hearing some of the condescension when being asked (or commanded) to do something irritates me a bit. Like, for instance, a puggy 3rd year gen surg resident who looks like she came straight from that Gardasil commercial (you know, that feminist, women’s power bitch at the end telling us about how you could be One Less? Evil men, spreading their icky, icky germs!).

She waltzes in, talking down to everyone in the room, because, gasp, we don’t react instantly to her commands, and wonders why the room isn’t prepared a completely different way than asked for by the attending’s card. An hour later (while the patient is under general anesthesia, mind you - bad, bad, bad), the surgery can finally begin. Had she been in the holding room prior to the procedure we might have dealt with this before hand. But what dumb fucks we were for not being all omnipotent! I cower at your Dansko's and beg for forgiveness.

I imagine that if I were on this rotation I’d think she was all cool and shit. Because I’d be internalizing like the mad-crazy medical student gunner I am. But I’m not. I’m on the other side of the curtain, dealing with blood pressures, respirations, keeping the patient from moving, trying to understand why the hospital scrubs have writing all over them (who do I call for a good time?), and other important, life maintaining items that anesthesia people do. Because people like to breath. It’s a good thing. Putting the patient in Trendelenberg at the instant a “request” is barked out does not imply that I need to be yelled at. I heard you the first time; pipe down their girly.

Since some of the surgeons have worked with me they have been quite nice about letting me wallow in my own brand of OAFAT (wah-fat: obligatory anesthesia fuck around time) before they get pushy. It’s been, for the most part, good. But girl-power chick needs to back the fuck off a bit and take a chill pill. You’re not god – yet. Though I imagine you think you are.

Couldn't Say It Better

I thought that I'd show you what goes through my mind daily - despite the fact I'm not actually setting up the room or am alone in the room when anything important occurs.

This is from Michelle at The Underwear Drawer - a hiliarious blog about an Anesthesia resident in NYC. If you've never read her stuff, you gotta lot of work to do.

What Makes It Awesome

What drives you into a particular field of medicine? Is it the love of a field, external influences such as family or friends, power and prestige within the medical community itself…money? Or, perhaps, it’s the desire to see instant results, receive gratification through well anticipated outcomes with a good resolution, the ability to think on your feet regarding the physiological, pharmacological, and pathological issues at present?

For me it is the latter and I know that Anesthesiology is certainly the fit for me. I have LOVED my time at my hospital during these short 7 days. I find myself seeking out the larger, more complex cases in order to see what steps are needed to navigate a successful anesthetic case. A patient waking up on time, with well-controlled pain, who offers their thanks (even if they won’t remember it when they leave) has been everything that I wanted out of medicine. Anesthesia is by far more complex than I’d ever originally thought and requires constant vigilance and quick thinking (even if you don't appreciate it on the other side of the curtain).

My brain is being challenged daily. I’m mentally exhausted at the end of some days because of the thought process involved when I run a case with guidance. Pimp sessions are more likely than not to leave me completely unable to answer - something I'm not fond of, but it leads to learning and motivation to understand the concepts behind the subject. This has not always been the case with many rotations I underwent last year.

I’ve also found the easy going and fun nature of most of the Anesthesiologists and CRNA’s I work with very influential towards this learning and it has prodded me to be ready for the next day. It has been extremely rewarding to take this elective and I can’t wait for the level 1 trauma centers where I will spend 2 months as away rotations.

Now, despite all of these things, I must say that it’s not been all roses. I’ve had some issues here and there, some intubations that didn’t go as well as I’d have liked and such. Bag-masking someone is my personal hell. I can’t do it very well and I always look like a fool when trying – since I invariably fail miserably when an attending is in the room.

Today I was forced to mask an obese patient for 20 minutes, on a paralyzing agent, in order to learn how to do it effectively. I was keeping this person alive purely by my ability to keep a good seal and keep oxygen flowing into their lungs. By the end my forearm muscles were screaming, but I was getting better. My favorite part? The attending asking what I wanted to do when I was hurting:

Attending: “So, what would you do?”

MSG: “I could either change hands and cross over myself…”

Attending: just looking at me.

MSG: “Or…I could suck it up and keep going.”

Attending: “Hey, we’re in Anesthesia. There’s no egos here.”

MSG: “Ummm, ask...for...some...help?”

Attending: “Right.”

Asking for help is not a sign of weakness. Cool.

WMSE

Sorry again for the delay in posts and the rather mundane nature of the last several. Clearly my life has been put on hiatus while other, shall we say “more pressing”, issues were addressed (the sagging Sitemeter numbers I've seen clearly indicate that you're getting bored). I apologize, but life as a Medstudentgod is not always as fun and exciting as you might imagine. Sometimes administrative bullshit takes precedence. So, on with the show!

****

What do you say to someone that makes your skin crawl and, despite all attempts to convey your complete abhorrence of their "being", continuously tries to talk to you? Someone that, for all other purposes, makes you want to vomit upon them in a horrible, Exorcist-like way? Yes, the Worst Medical Student Ever (WMSE - yes all of these are about him) is on the surgery floor right now and I’ve been able to see him in action during one case (since the gen surg team is apparently taking a vacation this week and overall surgical cases have been sparse).

This student encompasses everything that I hate about politics. An absolutely absurd specimen of medical training who is, unfortunately, completely capable of appearing highly intelligent and competent; but only for very short periods of time – like the time it takes to drain a rectal abscess. After 45 minutes of bullshiting his way around his utter clueless personality his asshole can't be corked shut anymore and shit spews forth from his dumbass as though he'd been hit with a bottle of Mag citrate.

Lord knows how much I hate this guy. What irks me the most is the fact that he wants to be an Anesthesiologist. He aspires to the same specialty that I hope to match into one day and it makes my blood boil to think about him as a "colleague". Hopefully I won’t find out if he matches come March since he’s already 7 months or more behind in his 3rd year rotations (using some lie about doing an Anesthesia away rotation when he was called out for failing Step 1 his first go around). I think knowing that someone like that could actually get a job in a field that requires a great deal of quick thinking might make me physically nauseous.

Honestly I feel that if he were to be in a medical school whose sole goal wasn’t to crank out as many minority MD’s as possible he’d have been ousted long ago. But, here he is, almost 3 years down, no prospects of stopping, and with the undeniable truth that he's cheated, lied, and bought his way to this point. Certainly the fact that Daddy has significant influence (both monetarily and politically) hasn’t influenced his status here. But that’s OK. I hate him, I know what kind of a tool he is, and that’s good enough for me.

Dental Hygiene

I have a friend who, while working in anatomy lab one day, told me what she thought about the dental students fucking us over on anatomy practicals. Her dad, apparently upon hearing about her brief consideration towards dentistry, told her that:

“If you want to be a doctor, be a doctor. If you want to be a garbage man, be a dentist.”

Clearly he didn't think highly of them and she never considered the career again.

Personally I’ve had some mixed feelings for the dental school and their students. I hate dentists - childhood fear really, but I’ve been able to overlook the mixed feelings I have towards people that desire to work in someone else’s mouth their whole life and have gotten along with some of them just fine. However, seeing a display within the OR while managing one of their cases (since most of the surgeons aren’t cutting this week and the oral “surgeons” are doing a lot of cases) has made me question their training.

If you’re a resident, especially a surgical resident, shouldn’t you know the general culture of the operating room? In particular, the fact that sterility is not something to eschew? I would think that would have been discussed on the very first day while getting your ID's and signing papers. Yet, I’ve seen several of the dental school’s oral surgery residents making huge mistakes in regards to being sterile with a complete lack of follow-up by their seniors.

My attention was caught while watching a girl scrubbing into a case, face exposed because her mask wasn't on, who suddenly appeared with the mask miraculously placed on her face. I wondered how she performed this feat, as no one was in the wash area to assist her prior to her entrance. I soon found out as she, in full sterile surgical gear, kept pushing her gloved hand onto her mask and adjusting it. Over and over again. I looked around, amazed that no one was saying anything. In surgery you would have been tossed out for an infraction like that! Where was the beat-down here that I'd seen or received on so many occasions during surgery?

Another resident would enter and leave the OR through the back door. A huge no-no since this door has signs plastered on it with large stop signs saying “Do not enter or leave through this door. Use the interior door, please.” People have been kicked out of surgeries for doing something this dumb. But, once again, nothing was said.

Another resident, moving around the patient while getting x-rays, kept brushing against the blue sterile cloth of the equipment table. He was warned once by the scrub-nurse, but he kept doing it. I have been made completely paranoid about this area and avoid it like the plague for fear of sudden death. He, however, didn’t seem to care. Probably because the case wasn’t stopped, new equipment wasn't procured, cases weren't moved back for hours, and the resident wasn't made to feel no larger than 2 inches for being a completely worthless idiot.

And still another resident (a lot of them in the room fucking stuff up, no?) didn’t seem to understand that wearing his mask was not an option. I counted 7 times where this guy left the room and entered without his mask pulled up. At least the attending got on him about that!

I seriously have to wonder about the training these "surgeons" are receiving when something that seems so inherent to any surgical field has been, apparently, completely ignored. Perhaps they are happier than most residents in medicine since they aren't belittled for infractions. But isn't that what makes you learn the correct way to perform procedures? Isn't that, at least to some degree, part of the reason surgeons are as compulsive about being clean as they are? I wonder what their infection rate is and who takes over once they give their patients endocarditis. Oh yeah, the real doctors.

Like Sand in a Bottle, So Go the Days of Our Lives

So time has passed and I have really nothing witty, informative, or interesting to write about. Sometimes days go by, people are intubated and managed by the best medical student to EVER do Anesthesia at my hospital (or so I’ve been told), and the world continues.

The news plays out, chefs are fired from a, regrettably, quite addictive TV reality show, and the tragedies keeps us wondering why the world is so fucked up. I feel quite sad about that bridge in Minnesota.

Hopefully more inspired writing to come, but right now I’m just not there.

Lovey-Dovey

Patient on the table, after have a spinal for anesthesia, looked up at the CRNA (RN who does anesthesia) and said in a very hilariously drunk and lovey-dovey voice:

"I love you!"

Apparently the patient was quite satisfied with her pain control.