All posts by pandabearmd

A Few Random Things

Futile Care, Residency, Uncategorized

Sick as Stink

We eye each other warily, Mr. Kelso and I. His remaining leg dangles over the side of the bed as we face each other.

“So, Mr. Kelso, what brings you to see us today?”

From top to bottom Mr. Kelso is a walking pathology textbook. An impossible combination of signs, symptoms, and disease who is probably only alive because his many comorbidities haven’t decided which will have the honor of finally dispatching him. He balances precariously on the edge of the bed, the exertion of which makes his oxygen saturation dip to alarming levels. Life itself is exertion to Mr. Kelso who has not been off of oxygen for ten years.

He dangles his scaly, pulsless foot and contemplates my question as his dessicated, lifeless toes with the crumbling nails and open ulcerating sores brush gently against the floor. I wish, not for the first time, that the nurse had left his socks on. Medicine is for the living. There’s nothing below Mr. Kelso’s knee that could possibly interest me and the smell of a foot going to meet it’s maker is incredibly bad, like a combination of sweat and a dead dog on the side of the road.

“My doctor told me to come in,” gasps Mr. Kelso as he adjusts his gown stretched tightly against the impressive pannus which flows over his thighs like fleshy lava. He pauses to suck deeply from the oxygen mask. “I’m having a little trouble breathing.”

“When did it start?” I ask philosophically as I study the the totality of Mr. Kelso, already trying to think how I’m going to fit him into the inadequate confines of a note. I’d hardly know where to begin. From a review of his old charts I know he has most of the usual abbreviations including one or two I had to look up. It’s an exacerbation of something that’s for sure but in a guy like Mr. Kelso we need to consider the possibility of congestive heart failure, asthma, emphysema, all of them, two of them, or none of them. It could certainly be a pulmonary embolism. Maybe not fluid overload from kidney failure because he was dialyzed yesterday but who know?

Maybe he’s had another heart attack. The long scar over his sternum signals that Mr. Kelso is no stranger to a little coronary artery disease now and then. He has more bypasses than the New Jersy Turnpike, not to mention (an almost offhand comment on most of his notes) “Multiple Stents. ” (Because, you know, after four or five the exact number is just trivia.)

Mr. Kelso gapes and his eyes focus on eternity somewhere behind my head. Good Lord. He’s a going to arrest and he’s a “full code.” I briefly contemplate the logistics of getting him back on the bed and how we’re going to do chest compressions through at least a foot of padding.

But then he removes his mask, sneezes on me, grunts, wipes his nose on his sleeve, and gasps, “Yesterday.”

“What’s wrong with me, Doc?”

“Everything, Mr. Kelso, Everything.”

And yet, a guy like Mr. Kelso barely raises an eyebrow around here. He’s a little fatter, a little sicker, and a little more decayed than most but it’s merely a question of degree. I can walk through any floor of the hospital and see dozens of people in almost as bad shape.

My point? Nothing really. Just that I don’t think a lot of people are prepared for exactly what they will find in medicine once they finish first and second year of medical school. Even shadowing or volunteering as a premed probably will only give you a brief taste of what to expect. You will see sick people, of course, but the enormity of their bad health can sometimes only be totally appreciated by admitting or following the patient for a long time.

My second non-point is that one of these days we will be forced to change the paradigm of modern American medicine. Currently, we operate from a sense that all life is priceless and that no effort should be spared to preserve life regardless of the cost, duration, or the quality of what we preserve. This outlook is certainly understandable but as health care, like any resource, is scarce and becomes more scarce and costly the more it is needed we can’t on one hand bemoan rising health care expenditures and on the other blithely spend hundreds of thousands of dollars on largely futile care which extend the lives of completely non-functional people by a span of a few months to a few years.

People have got to die sometimes. Seems obvious but have we become so sheltered from death that the families of my many 90-year-old demented patients (who should be allowed to die in peace) have forgotten this?

Call Still Sucks

And it is pointless and inhumane. The fact that my attendings and every other resident for the last hundred years have done call is irrelevant and even if it was, I don’t care. I think the “old school” attendings with their stories of how hard they had it are full of crap anyways.

Times have changed.

Hospitals today are high throughput patient mills compared to the boarding hotels they were forty years ago. A point I want to reinforce to you guys is that “call,” something you will be doing for from three to seven years depending on the choices you make, is not “call” at all but “work” and just an extension of the work day. In fact, on many rotations you will work harder on call than during the day because not only will you admit patients for the other teams but you will have to cross-cover their patients.

And yet, you will run across even some of your fellow residents who think there is nothing wrong with staying up all night every fourth day and, even though they are being cheated out of most of the money given to the hospital for their training (approximately $110,000 per resident per year from Medicare), not to mention working in conditions that would cause the lowliest hamburger-jockey to laugh contemptuously, will spout the same stale propaganda that has been used to justify this sort of abuse or the last fifty years.

I am sick, for example, of hearing “Patient Care” being used as if it were the atom bomb protecting us against improved pay and work conditions. Ask for more time off? Sorry. “Patient Care Comes First.” More money? “Your Medicare Direct Reimbursement is used for Patient Care.” A few hours sleep on call? “Sorry, We Need to Think about the Patients and their Care.”

If Patient Care is so important than why not have the attendings sleep in the hospital, the nurses work for free, and never let anybody go home for any reason at all except for the sleep required to ward off psychosis. Obviously Patient Care Comes First only if you are a resident and only because the hospital has our gonads in its firm but benevolent grip. Whenever you hear “Patient Care Comes First,” check your wallet and put your back to the wall because someone is getting ready to sodomize you after picking your pocket.

So Does Residency Training

I shower, brush my teeth, and shave every day. This takes about five or six minutes (ten tops) because I have a short haircut, a good razor (Gillette Mach 3) and am not a metrosexual. I was on call a few weeks back and my senior resident became somewhat irate because I had “vanished” for fifteen minutes in the early morning hours and she couldn’t get a hold of me.When I said I was showering, she looked at me with contempt and said, sarcastically, “Must be nice.”To which the only response is something to the effect of, “I shower and shave every day because I am not a shit bag.”

It’s a little thing but the resentment towards me for taking a few minutes to attend to the basic business of life was far out of proportion to the offense. Can you imagine working at any other job where someone would resent something like this?

Another quick story: I was on call last week. I had been working solid since 0630 that morning. My pagers were going off almost non-stop. For the last several days I had been in the grip of a weird gastrointestinal bug. I could go about an hour or two between bouts and I was even thinking of asking for an IV and a liter of fluid.

Going home was out of the question. You can’t just say, “Hey, I’m not feeling well, I’m taking the rest of the day (er, night) off.”

It got so bad that I had to set up a little communications command post in the crapper with my cell phone because the pagers don’t stop and I had to answer them. Plus I was admitting patients from the ED to all of the medicine services which is a full time job that doesn’t let up until five of six AM. (I was off service from EM which means I am a receiver, not a giver…and it is indeed better to give than receive.)

Can you think of any other job where you would be expected to stay on the job, much less show up, if a physician (me in this case) determined you were so sick you needed IV fluids?

Housekeeping and a Plea for Help

I broke down and bought a domain and as soon as I figure out the intricacies of WordPress or Typepad (I haven’t decided which) I’m going to transport the archives and start posting on www.pandabearmd.com. I confess that I am intimidated by the thought of using HTML, loading WordPress, and screwing around with that kind of thing.

If anybody knows where I can get a free or reasonably priced WordPress or Typepad template for a blog of this kind please email me. The ready-made templates provided by Typepad (which seems to work better than WordPress) are pretty crappy. Hell, if anybody knows how to add a sidebar item which will let me add links to my current template which you will see if you click on my new domain, please email me. I will give you my password and maybe you would do it for me in repayment for the many articles I have written and which I hope you have enjoyed.

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 6

Third Year

(Surgical specialties are usually grouped together in a one month block although they may do things differently at some schools-PB)

Surgical Specialties: Urology, Ophthalmology, Otolaryngology, and Orthopaedics

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. And since you typically only spend a week on each service with the weekend off in between, you will matter even less than usual. You could get an inflatable sex doll, slap a short white coat on it, wheel it around on rounds, and nobody would notice a thing except maybe that the good looking chick in the back was unusually quiet for a medical student and didn’t ask nearly as many annoying questions.

Your Pretend Responsibilities:
Hardly any. Come on now. You’re on each service for a week. That’s hardly enough time to learn where they keep the paper-clips much less be of any use. If you subtract the time you spend in mandatory lectures or “Continuity Clinic”(if your school has this) your face time is even more limited and all you are really good for is getting in the way. If your residents don’t like to teach you will feel this keenly.

Things You Should Learn:
Urology: Common disorders of the male urogenital system. Impotence (or Erectile Dysfunction as it is called to avoid offending the impotent) is big. It’s the bread and butter (or potatoes and sausage if you will) of urology. Common presentation of urological malignancy like bladder cancer, testicular cancer, and the like. The prostate, of course. It’s huge. Probably deserves a blog of its own. Urge, stress, or overflow incontinence. Buzzwords: VCUG and TURP.

Otolaryngology: Anatomy of the head and neck. Dysphagia, odynophagia, and when to worry about them. Common malignancies. Otitis media gone horribly wrong. How to stand in the operating room doing nothing for eight hours pretending to be interested. Buzzwords: Uvulopalatopharyngoplasty. PET.

Orthopaedic Surgery: How to talk to an orthopaedic surgeon when you call him at 3AM. In other words, how to describe fractures and dislocations completely and succinctly. This would also be as good a time as any to review musculoskeletal anatomy. Simple casting and splinting and when to call a consult even if the xray of the wrist looks fine. Work on you upper body strength or stay out of the OR.

Ophthalmology: Common disorders of the eye. Glaucoma. Diabetic retinopathy. Macular degeneration. Now would be a good time to learn how to use that expensive ophthalmascope they made you buy. Recognizing ocular emergencies (retinal artery occlusion, detached retina, globe injury). Recognizing things that are not emergencies (hyphema, corneal abrasion).

Things That Will Suck
Not that much. It’s a pretty good month with no call (typically) and no pretenses that you are part of the team and thus no need to fake enthusiasm. Still, if by this time in your career you are sick of shadowing (following a doctor around and watching what he does) you are going to be unhappy as you will do a lot of this.

Urology clinic is painful. Call me a homophobe but I lost interest in holding some other guy’s wedding tackle after…let’s say…thirty seconds. For being a holder, Boy George had nothing on me that week. I also do not, repeat do not, want to hear seventy-year-old men telling me about their sex lives. Sorry. If I give you some Viagra will you shut up? I find discussions of how your penis broke particularly disturbing.

I’m not mature enough for urology.

As I mentioned, head and neck surgeries of the kind you might get sucked into unless you have your slacker game on can last for days. I made the mistake of scrubbing in on a facial reconstruction surgery that started at 8AM and ended at some unknown time after 4PM when I had to scrub out for a mandatory didactic activity. I have never been so happy to sit in a conference room talking about empathy.

Cool Things About the Rotation:
Not that much. I guess it depends on you level of interest. I had a friend who had always dreamed of being an orthopaedic surgeon and he had the time of his life. It was bearable, the hours weren’t that bad, and it’s mostly interesting stuff when you think about it. If you don’t like something, well, it’s really only five days. I can endure anything for five days. By the time you’ve had enough it’s Friday afternoon.

Call:
None, generally. And since you’re something of a cross between a migrant worker and a hobo, nobody really knows you and it will take a supreme effort of will for your resident to remember your name, even if he wanted to wake you up at 3AM. Ophthalmology and Urology are not “call heavy” specialties either so even if you did have call, you’d probably do less than the resident.

Slacking Potential:
Fantastic. Got some personal business to attend? Significant other coming to town? New game console? Sponge Bob marathon? For a slacker this is your month and it will have everything: Rapid turnover? (check). Busy residents? (check). Confusion? (check). In fact, you could probably not even show up and nobody would know or care. I am a resident. I usually don’t know my medical students unless they introduce themselves and say, “Hey, Dr. Bear, I’m Joe Schmuckatelli and I’m working with you this month.” Imagine if the medical students switched every week and some weeks there were no medical students at all. And how do I know if you don’t actually have lecture, for example. Hell, I don’t even know your name. If I even care and you gave me some vague excuse or another I still wouldn’t care.

Let’s just say that if you have just come off of six months of general surgery, OB-Gyn, and medicine this rotation will give you a much needed breather. My wife referred to my surgical specialty month as “that month when you were home a lot.”

Two Minute Drill VI Special Edition: Hell Freezes Over

Specialty Selection

Physical Medicine and Rehabilitation

“It’s the end of the world! The end is here!” shouted the unit clerk as she pulled out clumps of her hair and rocked in her chair. This sort of thing is normal for a unit clerk so I wasn’t too alarmed until I saw the nurses tearing their scrubs and smearing ashes on their faces. The respiratory therapist pushed a vat of Koolaid towards the back and everywhere I looked there was wailing and gnashing of teeth. When I asked what was wrong the charge nurse, who had changed into sackcloth scrubs, pointed in horror to the “cubby.”

“He’s in there, Panda. Oh the humanity! It’s past 5PM! Surely the horsemen are abroad!”

Cautiously I made my way to the cubby (a little alcove where admitting physicians sit to do their paperwork) and was surprised to see a pleasant-looking fellow sitting at the computer studying lab values. But there was something odd about him. His white coat was not just white but pristine. It glowed under the fluorescent lights and the starched creases on the sleeves crackled as he moved his arm. His scrubs, too, were of a strange color the likes of which I had never seen and they appeared new or so clean that he must have been an ethereal phantom passing unsoiled among his ghostly patients. A shiny, electronic stethoscope with the price tag still on as if it had never been used glinted like burnished bronze from his pocket.

“Hi,” he said, turning from the screen, “I’m Dr. Jones, one of the PM&R residents. I’m almost done admitting one of my patients if you need the computer.”

And I was afraid.

But as I am a good (if sometimes wayward) son of my church and made of sterner stuff than the medical students outside in the hall cowering in the corners in the fetal position, I confronted this impossible creature.

“Spirit,” I said, “whether you come as a dark portent of the end times or whether you are merely a phantasm is it not true that Physical Medicine and Rehabilitation is a specialty which treats a wide range of problems from sore shoulders to spinal cord injuries as part of a multidisciplinary team and whose particular focus is planning and implementing physical and occupational therapy to alleviate these conditions?”

“This is so,” intoned the so-called Dr. Jones.

“And is it not true,” I continued, “that you are sometimes called Physiatrists and part of your dark art is to predict the long term consequences of muskuloskeletal injuries and to develop treatment strategies to alleviate these?”

“In this also you are correct,” said Dr. Jones quietly but with obvious menace.

“Is this not the specialty that deals with prosthetics? With orthotics?” I asked, “Is this also not true? Confess, spirit!”

“All of those things of which you speak are correct,” said the corporeal representation of the entity known as Dr. Jones, “But know you that my dominion extends also to movement disorders, muscle pain syndromes, and even unto manipulative medicine in whose service I have made a dark covenant with osteopathic physicians among whom my name is Legion.”

“But spirit, how can this be?” I was perplexed. “The hour is late. The sun sets behind the hills and you, a PM&R resident yet labor in our department, a department whose walls have never seen the likes of you in the morning much less after normal working hours. Is it not written that a PM&R resident knows not the lethargy of the early morning hour nor does he keep the watches of the night (or the late afternoon for that matter)? Does not your kind slumber on the weekends and know not the sting of call or long hours? How can these strange signs be ascribed to anything else but the apocalypse?”

“Oh, don’t worry,” laughed Dr. Jones, “This is the first patient I’ve admitted in two years. But I’m done so if you’ll excuse me…”

And then he was gone.

We still talk about that day when hell froze over.


Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 5

Third Year

(Some schools offer students the chance to rotate in the Emergency Department in third year while some only offer it as an elective in fourth year.-PB)

Emergency Medicine

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. But that’s all right. We’re happy to have you. It’s true you’re not much help but you will pull a few charts from the inexhaustible supply and it’s not like you’re in our way or anything like that. And, unlike almost every other rotation, we won’t fill your day with mindless scut. Even if we did, you don’t have to go very far to do it. Not to mention that as a rule, Emergency Medicine Physicians are pretty easy-going and you will rarely find the type of malignant personality that is common on some other rotations.

Your Pretend Responsibilities:
Pretty much what we do, albeit at a slower pace. Grab a chart, evaluate the patient, formulate a plan and present it to your resident or attending. You don’t have to move the meat. If you see five patients in a ten hour shift and do a really thorough job that’s not bad.

Things You Should Learn:
1. How to be succinct. It is generally not necessary to do a medicine-type presentation for every patient but the surgery-type (“Patient looked OK from door”) is not enough either. As an example, you can spin a long story about how badly the patient’s chest hurt after he mowed his lawn and how it felt like he was being stabbed and how he got, like, all sweaty or nauseous and had to, like, sit down and rest.

Or you can just say, “Mr Smith had sharp, severe exertional chest pain with diaphoresis and nausea relieved by rest.” Learn medical language. Not only is it precise but it saves time.

Bad: “Mr. Smith was feeling nauseous last night and threw up all over himself several times since yesterday. He’s hasn’t been feeling well lately and has been coughing up green stuff. He can’t hold anything down now and hasn’t eaten anything in two days. He has a burning pain in the left, lower part of his abdomen which he won’t let me touch. In fact, his abdomen is rigid.

Better: “Mr. Smith has a one-day history of nausea, vomiting, malaise, and a cough productive of green sputum along with constant left lower quadrant burning pain and and guarding.”

Best: “Mr. Smith was hurling like my prom date and I think we need to call surgery.”

2. How to let go. Come on. You can do it. There comes a point in every Emergency Medicine relationship when it is time to let somebody else have your patient. Tentative diagnosis made, appropriate tests ordered, patient stabilized, and admitting service notified. It’s time to wave goodbye to your pride and joy and hope that you raised them right and they won’t forget what you taught them. Why, you knew them when they first came in and now they’re all stable and pain free.

It almost brings a tear to your eye.

3. How to joke around a little. It’s all right. Some of the patients are idiots. It’s Okay to laugh at their exploits. You don’t have to get all pissy at some of the nicknames the nurses bestow on particularly odious patients either. There’s “The Lord of the Flies” in bay ten. “Mrs. Jabba” and “Jabba Junior” in room twelve. Not to mention “Your girlfriend,” drunk and stupid with garlands of crusted vomit in her hair screaming profanities in room six.

“Hey, Panda, can you keep your girlfriend quiet?”

“She’s my sister and no, I can’t.”

4. Maybe try to get a few procedures. Certainly offer to suture lacerations. You probably won’t get a chest tube but if you are interested, we might coach you through a central line or two. You can check for blood in stool all you want.

5. Look at a lot of CT scans, ultrasounds images, and films. This is high yield because almost everybody gets some imaging study or another and you can sit with an attending who, while not a radiologist, can point out most of the findings you are likely to encounter in any but the most obscure specialties.

Things That Will Suck
Everything if you don’t like it. Not everybody likes the pace. Some people like to deliberate a tad more and have just a little more information before they make a decision. They call this specialty “Internal Medicine.” No shame in that, of course. With the exception of those lazy bastards in PM&R, we are all a team and every member of the team is important. But if it bothers you to not have a clear diagnosis on every patient you will be desperately unhappy. I can only hope that you, at least, do not become one of those specialists who look disdainfully at Emergency Physicians when we do not immediately identify an obscure but obvious disease involving an organ system which they have spent seven years of residency and fellowship studying in excruciating detail.

Or, you just might be lazy and miss the opportunity to just sit around doing nothing like you do on a lot of other services.

You will also see a lot of smelly, nasty, obnoxious, and sometimes dangerous patients. You will either revel in it or not but there they are, scooped up and delivered fresh from the street in their natural condition which often involves a protective crust of vomit, feces, and other unspeakable substances. They don’t get sanitized for your protection until much later.

Cool Things About the Rotation:
If you can get over your brainwashing that every patient encounter must be a long, slow, mutually gratifying and environmentally pure simultaneous orgasm with metaphysical post-coital spooning, what’s there not to like? A huge variety of patients. Fast pace. Sassy nurses who won’t kiss your ass. Major trauma. Procedures. Even a lot of primary care if that’s your thing. And if you have a heart and like medicine at it’s most visceral, this is your specialty as it deals with a chief complaint which is addressed immediately and completely leading generally (believe it or not) to immense satisfaction on the part of the patient (if they are really sick, I mean, and not just looking for drugs or attention).

Call:
None. Zip. Zilch. You will work shifts and at most places, the medical students will only work the “rotator” schedule which is something like fourteen days in a month. Sure, the hours are screwy but I’ll take vampire hours with twelve or fourteen days off a month over Q4 call and 13-hour days with one day off every week.

Slacking Potential:
Good, because you are not tightly supervised unless you want to be an we are usually too busy to care where you are. It’s not like we have a lot of scut for you to do. But why would you want to be a slacker given that the hours are so good? Nothing motivates me to work hard more than the sure knowledge of when quitting time is. This is not to say that you will always get out exactly when you shift ends but at least you know when to start wrapping things up.


Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 4

Third Year

(Disclaimer: I hated surgery with the burning fire of a thousand suns so you may have a different experience-PB)

General Surgery

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. Your job on the surgery team is to be the butt of jokes and to give everybody someone to laugh at. Hey, I don’t make the rules. I’m just telling you how it is.

Your Pretend Responsibilities:
Post-operative management of patients on the wards. Assisting in the operating room although you can easily be replaced by any one of many finely crafted retractor frames. I all but refused to go to the OR after I learned about these things. “You mean to tell me that there is no reason for me to stand in the same place holding a retractor for six hours when all you have to do is hook up the frame and clamp the retractor to it? Why those no good, sadistic, lazy….”

But I digress.

Your other pretend responsibilities will include following patients as you would do on a medicine service as well as attending clinic where you will pretend to evaluate patients before presenting them to your attending.

Things You Should learn:
Ranson’s criteria are huge. I must have been asked about these at least once a day. (Ranson’s criteria help predict mortality from pancreatitis.) Also things like Charcot’s triad (fever, jaundice, and right upper quadrant pain), Reynolds pentad and other eponymous collections of symptoms. Surgeons love these things and if you can rattle them off your attending will think you are the best medical student ever even if you are an otherwise lazy piece of shit.

Don’t forget Panda’s Triad which is boredom, disinterestedness, and clock-watching.

Know the twenty-or-so common abdominal surgeries, their indications, and how they are done. If you know what a whipple is, for example, and the relevant anatomy you will do just fine in the OR under the pimping gun. Don’t ever say “Roux-en-Y” unless you know what it means. Also, don’t ever go into a case without at least knowing the patient’s name, his diagnosis, and the planned procedure.

Know how to scrub and what to do and where to stand in the OR. Extra points for knowing how to “self-glove” in a sterile manner because you might be expected to do this. Apparently, many scrub nurse have a clause in their contracts stating they don’t have to hold gloves for vagrants, migrant workers, cheerleaders, medical students, and others with no real purpose in their operating room.

Also know about wounds, how they heal, and the various methods used to dress and debride them. And for Mohammed’s sake learn how to tie a few common surgical knots. Practice before your rotation. Nothing says “dork” like throwing a granny knot.

Things That Will Suck:
Everything.

No. Really. If you don’t like surgery (and you will know how you feel about it after, oh, maybe five minutes) It all blows hard combining as it does all of the worst aspects of every other rotation with real hard work. Standing in a case holding a retractor or trying to stay awake and not falling into the sterile field (which I saw happen) is grueling. Medicine, by comparison, is not hard, just annoying.

The higher than usual numbers of malignant attendings and tired, bitchy residents just adds a little kick to the fecal jumbalaya which is your surgery rotation. But I have no sympathy for them and you, also, need to resist that temptation. Sympathy is in the dictionary between shit and syphilis. We lay in the beds we make. Nobody holds a gun to anybody’s head and forces them into this career. It sucks but it’s not as if your tired, pissed-off residents didn’t know this before they matched. Your third year rotation gives you a pretty good overview of the life of a surgery resident. You will be getting up just as early and leaving just as late. I hated every single minute of my surgery rotation, the only good thing about it being that it was my first rotation of third year and nothing that came after even came close to sucking as hard.


Cool Things About the Rotation:
Nothing. Seriously. If you don’t like it and have no interest in being a surgeon it is all a grind. Even surgeons will tell you this. Surgery is a calling. You either love it to the exclusion of almost everything else in life or you will resent it mightily. Family medicine, psychiatry, Emergency Medicine, and Internal Medicine residency programs are littered with ex-surgery interns who discovered that they had other interests in life and that, while it may have seemed cool at one time, it just wasn’t worth it in the end. Married surgery residents have almost a one-hundred percent divorce rate for a reason. You cannot have a family life as a surgery resident. Period. The eighty hour work week is still a joke in most programs and the simple mathematics of the week dictate that you can’t have Q3 call, work 100 hours a week, get the bare minimum of sleep, and spend the time with your wife and family that they deserve. There are 168 hours in the week. How much sleep do you need? Forty hours a week? Do the math. It’s five long years, sometimes six.

By contrast, as an Emergency Medicine resident I work about sixty hours a week for three years and will probably make more as an attending for half of the hours and about a third of the bullshit.

But you know, it’s surgery. There is no question that it is a useful, highly challenging field which will never be replaced by mid-levels or outsourced. If you’re young, healthy, and motivated and like this kind of thing you may find your true calling in life on your surgery rotation. A lot of my classmates loved this rotation and yearned for fourth year when they could line up more of it.

Call:
Useless like most medical student call but not completely useless. On trauma call you will be handed the “Monkey Sheet” (the History and Physical) and filling it out during the trauma will help your tired residents immensely. And you may be a real help during cases late at night or early in the morning when nobody is around. You’ll still hold the retractor but at least you’ll be standing opposite the surgeon and not leaning in at an impossible angle.

Slacking Potential:
Excellent. Other than rounding in the early, early morning your residents and attendings will be busy during the day and not making a career out of leading you and the rest of their entourage around the hospital. I’m sure your school has a minimum number of cases in which you must participate but nobody ever failed the rotation for not getting into a whipple. Maybe during your rotation nobody needed one. A colectomy here, a hernia repair there and you can build up enough cases to keep the wolves from your door. After this there are a dozen perfectly legitimate reasons not to scrub in on a case without having to ever resort to the “I’ve had the runs all day” ploy. If you don’t like it and would rather be a Slurpee jockey than a surgeon, OR time is pretty low-yield anyways. No reason to kill yourself.

Miscellaneous:

How to Scrub 1
How to Scrub 2
My First Day of Third Year

Ten Things I Like About My Job

Uncategorized

Anonymous writes: “Say, Uncle Panda, you’ve convinced me that medical training blows and that the only difference between being somebody’s prison girlfriend and residency is that your cell-mate/husband usually lets you sleep after he sodomizes you. Are there any good things about your job? ”

Excellent question. Naturally, it is easier and more interesting to complain about things. If all I did was opine about how much I liked everything and how wonderful, kind, and wise the entire medical profession was I think I’d probably have about six readers, all of them geeks, and all of them regularly exclaiming, “Darn, that Panda guy sure can write!” And, there would be just too much competition from one of many fine Smurf homage sites.

Not to mention that you would find reality far different than the rosy picture I painted.

Still, I do like my job and here are a few reasons. Some of them apply to my job in particular as Emergency Medicine is somewhat different than many of the traditional specialties, others apply to medicine in general.

1. I don’t have to internalize my patient’s complaints. Many of them are sick, really sick. The kind of sick that you, reader, may find hard to imagine living as you do in the prime of your youth and health. I see, almost every day, some example of the body’s seemingly inexhaustible capacity to hang on in the face of failing organs, deranged chemistry, brain damage, and absolutely horrific injuries. But it’s cool. I’m not that empathetic. I don’t believe the patients want that kind of thing anyways. Given a choice, most patients would prefer an authoritative physician who thoroughly understood their aortic stenosis and their congestive heart failure over some smarmy, slobbering empathy-whore.

2. Every now and then a patient comes in who is dismissed by the nurses, laughed at by the mid-levels, and generally treated like a malingerer until you walk in, bring your medical training to bear, and make an obvious diagnosis. Sheepish looks all around. Respect from the nurses who take pride that you have been brought up so well, envy from the mid-levels who keenly feel their lack of knowledge, and a gratitude from the patient who finally gets the respect he deserves. Medicine at it’s most visceral and gratifying. Cheeses and hams all around. (Absolute Doctor Rule Number One: Everybody gets the benefit of the doubt.)

3. I don’t care what you’ve heard, physicians are still respected by almost everybody, especially when either they or a family member are sick or injured. In our “Call-Me-Bob”, I’m OK, You’re OK society a physician is one of the few people still called by his title. I occasionally have a young, tattooed, patient making a career out of fighting authority who never-the-less struggles with the correct way to address a doctor. He knows first names are wrong. “Mister” is out of the question. It is finally, with relief, that he discovers “Doctor” is acceptable. Kind of sets the mood. If you act like a physician, you will be treated with respect. This goes back to not slobbering on the patients. They want kindness and respect but they don’t want you smothering them either or being their best friggin’ friend.

By the way, I always call patients by their title which is, at a minimum, Mister, Miss, or Mrs. My mother (who reads my blog, by the way) taught me good manners.

4. My colleagues are as profane and irreverent as I am making for a really fun work environment even when things are ostensibly blowing hard. While we are circumspect around the patients and in areas where the usual compassion fascists prowl, I have only heard Marines and sailors swear as much or tell more off-color jokes. This may bother some of you but (and I say this with respect) you can pound sand. If you don’t like it, go into a specialty at a program where they wouldn’t say shit if they had a mouthful, gather up your skirts, and waggle your fingers while making tsk–tsk noises to your heart’s content.

5. We get to avoid most of the rush hour traffic. I once had to drive to work at a normal time and it took me three times as long. Good Lord. It may be dark when I leave but all the traffic lights are blinking yellow.

6. Free food. Don’t underestimate it. At my program, we eat for free in the cafeteria. I probably drink about eight or nine Diet Cherry Cokes (the official soft drink of Panda Bear, MD) per day so the savings are huge. Plus it’s nice to have a perk or two. It makes one feel special.

7. Emergency Medicine gives me the opportunity to practice Christianity. I may hate doing it, it may make me ill, but if Christ washed the feet of beggars I can certainly remove some disgusting wino’s urine-soaked socks and examine his filthy, gnarly, fungus infested feet without complaint or change of expression and without making the wino feel like he is bothering me by coming in for some warmth and a meal. I hate doing it, of course, as I am no Mother Teresa but I hope the Lord gives me some credit for the action, not the thought.

Except for action, most compassion is metaphysical crap anyways.

8. Going home. It’s the best feeling in the world to get done with a shift, especially on or around the designated quitting time. This is probably unique to Emergency Medicine, especially in residency. Most residents have the devil’s own time escaping at the end of the day. There is always something that can stall your egress and it is usually something trivial or people without families, outside interests, or lives who get all of their social interaction at the hospital and want you to hang around. Not to mention that there is always work to do. You can stay at the hospital 24-hours a day seven days a week if you want and nobody would complain.

But that’s why they have a on-call team, not to mention night-float. I hate call but I do it. And I don’t try to pass off consults and admits that come in at 4:55PM to the day team because they came in during the day.

9. It is an interesting job. We see a little of just about everything from genital warts to leukemia. Sure, some things are bread-and-butter but not everything is. Major trauma is pretty cool too and I am working towards being as calm and collected as my senior residents and attendings.

10. I get to wear pyjamas to work.

Just a Few Random Things

A Day In The Life Of..., Uncategorized

Fast Freddie Johnson and the Man

The patient, a young black man, eyed me suspiciously. Apart from telling me that his name was Kareem, he had said very little during the initial assessment in the trauma bay and had made it to the CT scanner and back without saying more than ten words, total, to anybody. His GCS was 15 and he was hemodynamically stable so this was initially attributed to pain and fear. Other than the obviously fractured tibia, he was uninjured but as the pain medication kicked in and things settled down he still seemed reluctant to give us any information.

A group of his friends were in the hallway outside the trauma bay and they, too, were noncommittal even in regard to his last name. They eyed the two police officers from whom their friend had been fleeing before he smashed his stolen car into a tree and elected to plead the fifth in regard to their alleged friend.

“Come on,” said one of the cops, “You hang out with this guy and you don’t even know his last name?”

Shrugs all around. They had the police in check.

“Kareem,” I said, “I’m Doctor Bear, one of the residents on the trauma service. We’re going to get the orthopedic surgeons to look at you and I imagine they’ll be taking you to the operating room to fix your fracture.

“Kareem?” said the patient’s mother who had pushed her way into the trauma bay, “His name ain’t Kareem, it’s Freddie, Freddie Johnson …Baby, why you be tellin’ them yo’ name is Kareem?”

Mr. Johnson, demoted and revealed, shot his mother an angry look and I fully expected her to deny knowing her son.

The police left after we assured them that Mr. Johnson wouldn’t be going anywhere for awhile which was probably a mistake as only one day after an ORIF (Open Reduction, Internal Fixation) of his tibia, the taciturn Mr. Johnson limped out of the hospital on his crutches and we never saw him again. I guess we underestimated his desire to evade the law. Although we never really had a conversation and he glowered at me whenever I went into his room, I can’t find it in my heart to dislike Mr. Johnson. If you have to leave Against Medical Advice (AMA) this is the best way to do it, avoiding as it does the usual song and dance, the cajoling and stroking, that these things usually entail. I have often found myself earnestly trying to persuade a recalcitrant and unappreciative patient to stay when my heart yearns to say, “Hey, if you want to leave before I can arrange to have home IV antibiotics then don’t let the door give you a staph infection as it hits you on your ass on the way out.”

Of course you can’t really say something like that.

Residency and Call Revisited.

I despise call. And I don’t care to justify my dislike for it by claiming that patient care suffers if the residents are tired. I don’t even know if I really buy into the notion that tired residents make a lot of mistakes, and frankly, I don’t care. It certainly seems like a difficult hypothesis to test and I would hate to have my sleep dictated by the results of some pointy-headed geek’s study.

No, I dislike call for the more visceral but just as legitimate reason that it is inhumane to deprive a person of sleep for anything short of combat operations or genuine medical emergencies. The problem is that everything nowadays is an emergency, even things that aren’t.

“Call” is a misnomer by the way. It’s not “call,” it’s “work.” Attendings have call. They get to go about their business until called in for an actual emergency. Otherwise they take a phone report from the resident on call and say, “Okay, admit the patient and I’ll see him in the morning.” Residents on call generally work nonstop from the early evening until they are allowed to go home the next day. If it’s not an admission in the Emergency Department it’s an issue regarding one of the many patients they are cross-covering.

There was a time, many years ago, when the whole crazy system began when resident call did not mean a sleepless night every third or fourth day. Because people routinely died from the first major illness they acquired instead of collecting them over the years and living longer thanks to medical advances, hospitals were a lot slower-paced then they are today with a more stable census for a service (as hospital stays used to stretch for weeks for things that are treated as an outpatient today) and fewer acute issues that needed to be managed. As a result, the house staff in the fifties may have stayed overnight in the hospital often but I guarantee they slept a lot more than we do today.

But, as I said, today everything is an Emergency and has to be done right away. Not only are we dealing with an older and sicker population but expectations of the public are a lot higher than they used to be. Fifty years ago it was recognized that some diseases were death sentences and the priest and the undertaker were more likely to be called than the doctor. Today, we never say die and we routinely admit, treat, and discharge people who fifty years ago could not possibly have lived long enough to acquire so many comorbid conditions. The combination, for example, of congestive heart failure, diabetes, emphysema, chronic renal failure, morbid obesity, and ischemic heart disease (any one of which was fatal a generation ago) is so common that I’m thinking of having a stamp made so I don’t have to keep writing it on the chart.

So there is very little down-time on a typical medicine or surgery service and you can count on a steady stream of admissions from the Emergency Department to keep you occupied through the night. The Emergency Department, for it’s part, is turning into a miniature and almost self-contained hospital complete with a census of admitted patients who linger in the department waiting for a bed.

What to do about it? Who knows. I only mention it because, with the exception of one month next year, this month is officially my last call month in my medical career. Nothing but shift work from here on out. Emergency Medicine, Baby!

No point, just wanted to gloat.

Letter to A Patient’s Husband
(With a nod to Scalpelorsword for the idea-PB)

Dear Mr. Jones,

I know you accused me of not caring and, on the surface, it may appear that way but I assure you the reality is more complex than that. I know your wife is morbidly obese. I know she suffers from a host of serious and eventually lethal medical conditions. I realize she was in a car accident last week but other than a few bruises, she is all right and while I can understand your reluctance to take her home, you must because she can’t stay here.

Yes, she is a big woman. In fact, she could barely fit into the CT scanner. Yes, she has trouble walking. I have had physical therapy working with here and they inform me that they have done all that they can do. I also am well aware that he has trouble breathing. This is a combination of her emphysema, her current smoking habit, and obstructive sleep apnea from her obesity. I also realize that she seems tired but as you probably noticed, she’s not getting a lot of sleep at night, particularly because she refuses to wear her CPAP mask.

Yes, I understand it’s uncomfortable. I’d hate to have to wear it myself but it’s all I’ve got in my bag of tricks.

I am sorry. We can’t keep her. She came to us in poor health after an automobile accident and she’s going to leave in the same condition that we got her because there is nothing more that we can do about her chronic medical conditions. We took great pains to rule out any occult injuries to her brain and spinal cord and she has been in the hospital on our service many, many days longer than we typically keep uninjured trauma patients, many of who we discharge from the Emergency Department after a few hours of observation.

I can understand your reluctance to take her home. I believe you when you tell me that all she does is sit on the coach and watch TV except when she struggles out of it to use the bathroom. I wish that we could send her to a skilled nursing facility but as she has no insurance and you can’t afford it, this is not an option. She may or may not qualify for Medicaid but we can’t keep her here waiting for the decision. You will just have to take her home.

How will you get her up the steps? You have two sons. I saw them here yesterday. They may live a couple of hours away but they’re just going to have to drive back to town and help their mother. She is your responsibility and theirs. That’s why they call it a family. In fact, the stability of our world depends on families acting as self-supporting units. Break the bond of family and you have either a decaying European-style welfare society dying a selfish and lingering death or a catastrophe like the former Soviet Union which proved that if everybody is responsible for everyone else, no one is.

I’m sorry to place the whole burden of Western civilization on your shoulders, what with you living in a trailer with nothing but basic cable, but there it is. She is your burden. We need this bed for the never ending backlog of patients, some even sicker than your wife, many of whom are sitting in hall beds in the Emergency Department as we speak.

So you see, it’s not that I don’t care, it’s that I can’t care. I can’t take her home with me and assign my wife as her nurse. We can’t keep her in a scarce hospital bed for the rest of her life with her own private nurses and therapists to assist her. Despite what you may have heard, we are not magicians and I we cannot cure what afflicts your wife. I’m not even sure that we could help her if she wanted our help which she apparently does not. I can’t, for example, hold the CPAP mask on her face all night against her will or force her to take insulin shots. She could have me arrested for assault. She’s an adult. We all lay in the beds we make. We’re not doing a thing for her but catering to her whims, something you might want to stop doing by the way.

She can get up if motivated. I have seen her, just this morning, heave out of her bed and transfer to the bedside commode. I suggest if she asks you for some food you tell her to get it herself.

You asked if I am sending her home to die. Of course not. But she is going to die. I’d say her chances of being alive five years from now are zero as she is a setup for all kinds of medical badness. But, like I said, we can’t keep her here for the next year or two hoping to preempt the next medical crisis. Call the ambulance if there is any sudden change in her condition.

You were right about one thing. In the end, hiring a nurse to help you at home would be a lot cheaper than the inevitable hospital costs your wife will incur over the next five years as her health continues to deteriorate and fruitless regular hospital admissions turn into fruitless and spectacularly expensive ICU admissions. But I’m just a resident. I don’t make public policy. Even if I did, while your idea makes sense economically, I’m not sure I’d want to structure society to completely remove the burden of individual responsibility.

Good Luck. I wish I could do more but I can’t.

Sincerely,

Dr. Bear

How to Write Your AMCAS Personal Statement

AMCAS Personal Statement, Uncategorized

Feel Free To Use These…

(As many of you know, the personal statement on your AMCAS application is an important piece of the medical school admission puzzle. A good personal statement can land you an interview while a bad one can make an otherwise strong candidate look insipid. I was going through my computer and I found a few ideas to start you off on your personal statements. Feel free to use them-PB)

Sample 1
I had been arrested two weeks before for obstructing logging in the Xocaatl tribe’s ancestral hunting grounds and it was hot in that Mexican jail. Damned hot. The kind of heat that sneaks up behind you and throttles you in manner very similar to that employed by my cell-mate Fernando as he fumbled at his belt while hissing dark Spanish threats into my ear. I think he was warning me not to shout out for the guards, something that I would never do as our personal morality should never be forced on others. Then the pain came. I gritted my teeth and forced back the tears. Homophobia is wrong, I told myself…

Sample 2
His name was Lavon Quintravion Jones, a 24-year-old white male…

Sample 3
The genital mutilation ritual practiced among the Laconda Tribe in the Peruvian foothills looked painful. And it was. Very, very painful. And, as the cermonial dagger was first dipped in the urine of a llama, I don’t think it was very sanitary either. Never-the-less I have always thrived in diverse cultures.

“We need to celebrate diversity.” I said to the flight medic as the Peruvian Army helicopter airlifted me to the hospital in Lima where emergency surgery would later save most of my penis.

“El dumbass mas grande en el mundo,” The flight medic said as he adjusted my oxygen mask and I was gratified that he agreed. (I guess my six-day immersion Spanish course was not a waste after all!)…

Sample 4
It’s all about the kittens. I remember my first experience with my pregnant tabby Snowball as the genesis of my desire to be a doctor and my hope to eventually specialize in OB/Gyn. “Hold her still,” I said to my friend Skeeter, “I’m counting parts here and I think we only have enough for five and a half kittens.”

Even then, at the age of twelve, I was strong believer in reproductive freedom for all female mammals…


Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 3

Third Year

Internal Medicine (“Medicine”)

Your Real Responsibilities:
Nothing. You’re a medical student. Remember those red-shirted crew members on Star Trek? That’s kind of like you. Your only function is to walk around filling out the scene. Sometimes bad things will happen to you, sometimes you will provide comic relief, but mostly you will just fade into the background, indistinguishable from any other medical student.

Your Pretend Responsibilities:
Managing patients on the wards. Seeing patients in clinic and presenting them to your attendings and residents. Admitting and discharging patients under the supervision of your residents and learning to write the appropriate orders.

Things You Should learn:
Everything. Internal medicine (along with General Surgery) forms the backbone of the entire medical profession. It is medicine in its purest form complete with meticulous history-taking, a thorough physical exam, a comprehensive differential diagnosis, a sound plan with the appropriate testing, and either a definitive treatment or the appropriate referral. It is both traditional, as the internal medicine ethos would not be unfamiliar to the ancients, and cutting-edge, as new research is continuously incorporated into the profession.

So there is a lot to know. Rather than trying to list things, let me give you one of the only really useful mnemonics in medicine which is “VINDICATE.” I generally hate mnemonics but this one will let you systematically come up with a differential diagnosis from which further testing and treatment may be derived. The causes of every illness known to man are:

Vascular
Infection
Neoplasm (Cancer)
Drugs
Inflammatory/Idiopathic/Iatrogenic
Congenital
Autoimmune
Trauma
Endocrine/Metabolic

When you’re in a bind and staring at and acre or two of blank space on your note for your assessment and plan, just take a deep breath and remember VINDICATE.

Things That Will Suck:
Did I mention it was medicine? As bears shit in the woods, the Pope is Catholic, and death invariably follows taxes, medicine attendings love to round. And round and round and round, often well beyond the point where you care about anything but making it stop.

Rounding, for those of you who don’t know, involves visiting, as a group, every patient on your census to discuss their illness and the plan. Surgery rounds are sometimes of the variety, “Patient looks fine from door, let’s move on.” Medicine rounds, however, proceed at a glacial pace as every single aspect of the patient, his disease, his lab values, and his prognosis are discussed in excruciating detail. This is where you may have a 45-minute ad hoc lecture about a patient’s normal but slightly low sodium value and what it means for him. Then you will discuss the next patient’s potassium for half an hour.

Merck developed a probe that gave continuous readings of serum electrolytes but they had to take it off the market after internists started hanging themselves with their stethoscopes.

Not to mention that every possible cause of the patient’s symptoms, no matter how unlikely, will be trotted out like so much horseflesh to be poked, prodded, examined, and finally sent back to the corral. It is a good way to learn medicine, don’t get me wrong, but my feet hurt all the time on that rotation and I developed plantar fasciitis from standing up and walking for eight hours a day.

“Don’t they have anything better to do?” you ask. Well, no. This is what they do. Internal medicine is light on the procedures but heavy on the thinking.

Cool Things About the Rotation:
1. Morning report: Almost every program has a formal teaching session in the morning where a case is presented to the residents. It is usually in a question and answer format where the presenter starts with the presenting complaint and symptoms and the residents ask appropriate questions about the history, review of systems, physical exam and all the other elements of a good patient encounter. This leads to the creation of a differential diagnosis which is narrowed down to the most likely disease after which a short presentation on the final diagnosis is given. For my money, this is the best way to learn medicine. It’s interactive, it’s fun, and even the pimping is usually in good spirit.

2. The opportunity to rotate on sub-specialty services: I landed nephrology and cardiology (two weeks each) as my subspecialties during my two-month-long medicine rotation. Nephrology attendings, for their part, are like general medicine attendings on crystal meth, at least when it comes to their preoccupation with electrolytes and they are, as a class, perpetually exasperated that their medical students, most of who are just trying to survive, cannot identify garden-variety mixed acid-base disorders. Still, these kinds of rotations give you good exposure to the whole range of medicine.

3. Medicine is very cool. Internists have my deepest respect but it’s not something I wanted to do, what with my short attention span and poor memory.

Call:
Useless, like most medical student call. You’ll basically just follow your resident around as he grinds out admission after admission in the best cookie-cutter fashion. As there is no difference between an admission done at 8PM and one done at 3AM (except that at 3AM you are too tired to give a crap) there is no reason to lose sleep. You can learn all you need to know and still get a good night’s sleep except that your faculty is bound and determined that as they suffered, so shall you.

Slacking Potential:
Medium. Rounds don’t actually last all day. You may have a couple of hours to vanish and either take a nap or study. Generally, after formal rounds you have “work rounds” where your residents will go back to their patients and implement the plans discussed on rounds. Since you are not responsible for any aspect of patient care, your presence is not required and after you make yourself aware of what is going on with all the patients you are following, the day is pretty much your own unless until sign-out in the late afternoon. Like most inpatient rotations, expect early hours but not as early as OB/Gyn or surgery where they round early to get it out of the way so they can do their real work.

Miscellaneous:

A Typical Day on a Medicine Service
A Typical Day as a Medical Student Part 1
A Typical Day as a Medical Student Part 2

Panda’s Quick and Dirty Guide to Third Year Rotations: Part 2

Third Year

Pediatrics

Your Real Responsibilities:
Nothing. You’re a medical student. You don’t count. I hear that in Arizona they’re going to replace medical students with migrant workers. Sure, they’ll have to pay them minimum wage but this is peanuts compared to the cost of educating a medical student. This way the hospital will save money, the employees will still have somebody to look down on, and the migrant workers can always mop the floors or do other useful work, something that you can never get out of a medical student.

Your Pretend Responsibilities:
Managing pediatric patients on an in-patient service. Attending pediatric outpatient clinics and learning to handle the breathtaking excitement.

Things You Should learn:
Presentations and treatments for common pediatric problems like rashes, diarrhea, colds, and vomiting. Developmental stages of childhood, normal milestones, and what to do or who to call if the child is not meeting them. Common congenital conditions. The major chromosomal abnormalities (like Trisomy 21), common congenital heart defects. Diagnosing and managing the more serious pediatric diseases. Identifying child abuse (a big one in my book). Learning how to examine sick and well kids without having them scream in fright during the whole exam.

Otitis Media. The big one. Deserves a whole blog of its own.

Things That Will Suck:
1. Well, it’s pediatrics. It all sucks if you don’t like kids. I have my own kids so I had a running start at disliking it. Other than that it’s not too bad. Inpatient pediatrics is as bad (or as good) as inpatient medicine. You will round, present, and take call. The primary philosophical difference between pediatrics and medicine is that most kids will get better and make a complete recovery, something you will not see that often on an adult medicine service where you sometimes feel like you are playing “Keep Away” with the grim reaper. But ward months are ward months and call is call. Rounding sucks no matter on what rotation you do it.

2. There is no clinic known to man more boring than outpatient pediatrics. Most kids are just not that sick but their parents bring them to the doctor with distressing frequency. The major culprit is the “Well Child Check.” The Well Child Check is a periodic screening exam to make sure that kids are growing appropriately and have all of their immunizations. If you can think of something more mindless than asking the same questions over and over about usually healthy children and plotting their height and weight on a growth chart then you have probably worked at more crappy minimum wage jobs than most of us.

Like two men and a ham, pediatric clinic can seem an eternity. The hours flow like thick syrup. Having to ask the questions in Spanish cuts the excitement in half.

Cool Things About the Rotation:
1. Well, they are kids after all. Who doesn’t like kids, especially if they are not yours and you don’t have to take them home? They are kind of cute and every now and then you will get a stupid smile on your face which you can’t get rid of.

2. Their are few things as gratifying as seeing a really sick kid get well through medical intervention. And, while you may not see this as a medical student, running a successful code on a child is probably the best feeling in the world (just like having to call the code is one of the worst).

3. The residents and attendings are fairly benign. Malignant people, as a rule, don’t go into pediatrics preferring as they do to keep their options open in Med/Peds. Additionally, if you want to know the one specialty that is a calling it’s pediatrics. The pay is bad, the hours are long, but people do it because they love it.

Call:
Fairly lame like most medical student call. You will soon grow tired of hiking down to the Emergency Department to help admit yet another asthma exacerbation. Or dehydration and fever from gastroenteritis. Still, kids are generally not as sick as adults even when they are admitted to the hospital so for the same size census, you will get fewer floor calls. I suppose that’s something. You know how I feel about losing sleep. As a resident it’s unavoidable as not only are you responsible for the patients but you are also getting paid, things that are not true for medical students. Have I said this before? I think it’s dumb for a medical student to answer floor calls as he is just going to have to page his resident for guidance. I say eliminate the middle-man.

Slacking Potential:
Not so good. Terrible in fact. It’s just medicine for kids with all of the rounding, morning reporting, conferencing, and other mandatory activities. When you’re doing your ward months you will pretty much be stuck with your team all day, every day so if pediatrics isn’t your bag you are out of luck. Clinics are, of course, mandatory, usually pretty busy, and dull.

Panda’s Quick n’ Dirty Guide to Third Year Rotations: Part 1

Third Year

Obstetrics and Gynecology (OB/Gyn)

Your Real Responsibilities:
Nothing. You’re a student and you don’t count. Every medical student in the hospital could vanish and apart from less crowding on the elevators, nobody would notice.

Your Pretend Responsibilities:
Following pregnant woman pre-, ante-, and post-partum. Assisting in vaginal and Cesarean deliveries. Assisting in gynecological surgeries including hysterectomies, vulvecvtomies, and salpingectomies. Seeing patients in clinic with various gynecological problems who you will present to your attendings and residents. You will probably “shadow” a resident at first. Your level of independence will depend on the school, the attendings, and your level of interest.

Things You Should learn:
1. Pelvic Exams. Don’t be squeamish. They call it a bimanual for a reason. The first fifty you do all you’ll be able to say is that it’s warmer in there than outside but after a while you’ll get the hang of it.
2. Assessment of labor. Learn how to assess the cervix for dilation and effacement. Recognize the stages of labor and which stage the woman is in if you feel the baby’s ears while checking the cervix.
3. Recognizing common complications of pregnancy (placenta previa, accreta, malpresentation, pre-ecclampsia, etc), knowing who to call and what to do in the meantime.
4. Treatment of STDs.
5. Causes of abnormal vaginal bleeding and what to do about them.
6. Common gynecological malignancies.

Things That Will Suck:
1. The hours. The early, early hours. Best to just suck it up and go to bed early every night. Tivo American Idol if you must but it is not unusual to pre-round at 0500 on OB which means that unless you sleep in your clothes and don’t brush your teeth you will have to get up at hours that would make dairy farmers cringe.

2. Vaginal Discharge: Are you some kind of freak? How could anybody possibly enjoy looking at and smelling green frothy discharge pouring out of an orifice that would turn Puff Daddy gay if he were to merely gaze at it. I have seen some horrific sights in Gynecology clinic. Visions of terror that have made even hardened OB/Gyn residents recoil in horror while their less-seasoned colleagues wept and spread ashes on their faces. They don’t call it the whiff test for nothing.

3. OB/Gyn residents. I’m conflicted on this. They’re not necessarily malignant, just cliquish. Definitely cold towards medical students unless you really show an interest which, frankly, is hard to do if you’re not interested (obviously).

Cool Things About the Rotation:
1. Once you get past the feces, urine, smells, screaming, and other truly frightful aspects of childbirth which they don’t show on the Discovery Channel (but I don’t have HDTV) it is kind of cool. Everybody is usually pretty happy to see the baby, even mothers who you know will be going back to their crack pipe an hour after discharge. Hope springs eternal.

2. A good variety of things in one rotation, ranging from primary care to incredibly intricate oncological surgeries. If you don’t like looking at “wedding tackle” this is also your rotation. Plus, although there are exceptions, female patients are generally less nasty than men.

3. Clinic weeks: Generally, when you are on the outpatient part of your rotation the hours will be nine-to-five with no call.

Call:
Idiotic, like most medical student call. Still, take advantage of the opportunity to get more involved in deliveries at night when there are fewer people around and you have a better chance to assist in a C-section doing something more than holding a retractor. You will mostly do call in OB triage.

Slacking Potential:
Not so good. On clinic weeks you definitely have to be in clinic and it’s hard to stand around doing nothing in that kind of exposed environment. Still, you can work slow and “just miss” picking up a chart from the door of a new patient. Although I kind of liked OB/Gyn, I can understand completely how after a couple of “close encounters” one might decide that they have had enough.

On Obstetrics you will have to round and since OB is busy, they have very well organized rounds and morning reports. No getting out of it. If you don’t want to go to the OR you can probably hide-and-slide when you are on “Benign Gyn” or “Tumor Gyn” but you will get dragged into a certain number of C-sections even if you have sworn an oath to all of the pagan gods that you will cook and eat your own entrails before you would match into OB/Gyn.

Misc:

What you will do an intern.

On the Shoulders of Giants

Articles You Must Read, Uncategorized

Shaman Healer of the Lame Caribou Clan

(After years of research, French anthropologists have managed to translate the famous cave paintings of Lascaux. The full translation will appear in next month’s “Journal of Linguistic Anthropology” but I thought I’d publish a sneak preview. -PB)

Me. Tharg. Shaman Healer of the Lame Caribou clan. Master of the Elk. Spirit-Hunter of the Sky Bison who is called Tharg-Who-Outran-Cave-Bear. I paint this in the Cold Time after the rains when the moon shines like new flint by glow of Brother Flame deep in the caves of our ancestors.

Troubled times. Like mastadon balancing on ice floe is to be Shaman of clan. Precarious, like squirrel caught between tree and wolverine. Like seal pup in path of charging walrus. You get picture.

“New magic salve,” say Olerg, wandering master of lore,”much better old salve. From dung snow fox.”

“Ward off tiger?” Olerg smile too much. Like crazed hyena.

“Tiger? New salve ward off even charging musk oxen. Know Tholar and Gronak?”

“My two brother shaman whose eyes dark from spell at birth?”

“Yes. Salve save them from musk ox. I Swear by Otter spirit. Study was double-blinded.”

Roll eyes. Old salve plenty good.

“Here, have spear with fox totem,” say Olerg offering crappy Neandrathal spear.

“I thank you, oh Olerg, my brother. Have plenty from last visit. But great joy have I for haunch of elk.”

“Oh wonderous spear!” say Otter-spawn, Shaman-to-be, resides-in-cave lo these past winters, “I take?”

Otter-spawn Chief of those-who-reside-in-cave and from me learn dark arts of shaman. Good boy but lazy.

“I go my fire, Otter-spawn. Keep the long watches of the night. Othar has demon of pestilent bowel and need sacred smoke when Sister Moon dips to embrace of far hills. Trulak need horn of great elk when Sister Owl return to tree. Sound ram horn if not work.”

“I abase myself oh Tharg-Who-Outran-Cave-Bear but I, too, go to my fire now,” Say Otter-spawn.

“Who will keep watches of night?”

“Is wonderous puzzlement,” say Otter-spawn, “But great hearth-fire in sky has passed in number like petals of tundra blossom and great spirit commands that He-Who-resides-in-Cave also lie by fire, gnawing rib of great sloth.”

“Does not Cougar-paw reside-in-cave?”

“He reside-in-cave of Bone Diviner in valley of snow hare. Not return for many moons.”

“Twisted-crow?”

“In service of Painted Eagle clan.”

“Go then,” I irritated, “But when Tharg reside-in-cave, took night watches in number like bison on plain.”

“Fetid Badger,” I call. Him best Shaman-pupil.

“I grovel oh Tharg-Who-Outran-Cave bear,” say Fetid Badger. Other pupils cower behind.

“If sky-wolf eat sister moon and woman yet bleed, what cause?” Simple question. They third winter pupils.

“Curse of Otah, the Cave Demon?” Ask Fetid Badger, like tremulous new-born caribou.

“Bah. Laughing Brook?”

Laughing Brook knit sloping brow. “Spell of Wola, the Womb Blighter?”

“Not see picture-on-rock? Not listen song of ancestors?” I irritated again, “Come pupils, hear thunder of hoofs, think bison, not cave yak. Go prepare magic wall picture of many cause womb bleeding.”

Ragrak, Chief of Lame Caribou clan stride into cave. Pupils cower, urinate submissively.

“Tharg Who-Outran-Cave-Bear!” growl Chief, “Ill tidings I bring.”

“What is problem?”

“Know you new female stolen before rains from Clan of Painted Eagle?” Ask Chief.

“Female with hair like mane of horse?”

“That her. And haunches like snow leopard, hips like fertile hills, heavy with promise of many fine sons.” Chief kick last of pupils out cave. Chief old, hair like snow of many winters. See where this going.

“Sometimes brother ferret not want come out of den.” say chief.

“Not understand.”

“No longer rampant stallion but seal pup, soft and helpless.” Chief annoyed.

“Have new salve. Dung of snow fox. You try.”

Clinical Evaluations

Articles You Must Read, Medical School, Uncategorized

Actual Evaluation by My Residents and Attendings

(Just for old time’s sake I reviewed my Dean’s letter. Man, those were the days! -PB)

OB/Gyn: Student is on time and does everything asked of him willingly and with good humor but seemed uninterested in assisting in any more vaginal deliveries than were required to pass the rotation. Actually winced, yes winced, when he was sprayed with urine and feces during one particularly rapid delivery. Commented to me that it was “Nothing like the Discovery Channel.”

OB/Gyn: Student Doctor Bear is on time and cheerful but does not fight hard enough to be the first to see patients complaining of vaginal discharge. I don’t think he should fail the rotation but I am giving him low marks for referring to our weekly STD clinic as “Kooter Patrol.” I also caught him rolling his eyes as I lectured a young, single, G5P4004 on the need for greater personal responsibility. I didn’t quite understand what he meant when he invited me to “repeat my advice to the wall and see if there was any difference” but I think he was making fun of me. Student Doctor Bear also showed no interest in standing around doing nothing while I performed a particularly difficult colposcopy.

General Surgery: Student Doctor Bear did everything asked of him but was singularly unenthusiastic about holding a retractor for six hours. He does not seem to enjoy call and never seems to either know or care about the answers to the random trivia question I ask him just to keep him on his toes.

Medicine: Does not seem enthusiastic. Once actually sat down (!) during rounds…and the attending and all of the residents were still standing! Had an insolent, “you people keep talking while I rest my feet,” expression on his face and ignored every frantic hand gesture to stand up before he made the attending mad. When the attending asked, with admirable sarcasm, “Are you tired, Student Doctor Bear?” he said, “Yes,” and persisted in his sitting position until we had moved to the next patient. And then, oh weep thou heavens and hide thine eyes in shame, when the attending suggested that maybe he wasn’t cut out for internal medicine he replied, “You’re probably right about that.”

Medicine: For reasons unknown to me, Student Doctor Bear is uninterested in electrolytes. Even after spending a brief forty-five minutes discussing a patient’s Potassium (Peace Be Upon Its Holy Name) level his only comment was, “So, do you think we need to supplement it?” Supplement it? Is the wind’s name Mariah? Can we began to explore the intricacies of Potassium (PBUIHN) in the brief time we had between five PM and eight PM when the silly rules require us to let our medical students go home to study?

Pediatrics: A good medical student but he has kids of his own so I don’t think he believes us when we say how great working with kids is. Changes diapers like a pro and is not awkward at all when handling the babies.

Heme-Onc: Did not directly observe the medical student. If you tell me he was on the rotation I’ll believe you and I do seem to remember catching a brief glimpse of him hanging way, way back in the team but when I blinked he was gone. I could probably review the hospital surveillance tapes if you really need an evaluation but I suspect finding more than a few seconds of footage will be more difficult than locating Big Foot.

Surgery: Not a good medical student at all. Despite never having been in an operating room, rotated on a surgery team, observed any operations, or completed a surgery residency, Student Doctor Bear displays absolutely no knowledge of how we do things in the OR, where to stand, and what my favorite music is. And this was his his second day of third year, for crying out loud. And he is woefully ignorant of the collateral circulation supplying the anterior two-thirds of the left adrenal gland even though he should have learned this in first year anatomy.

Family Medicine: I detected a lot of resistance from Student Doctor Bear. He seems reluctant to hug the patients and his sympathetic nodding skills are woefully inadequate. His empathy skills also need work. For example, when a patient complains about knee pain Student Doctor Bear needs to refer her to physical therapy, not comment that it is “No wonder because every time you stand up you squat-press a small German car.”

Family Medicine: He’s not buying it. Student Doctor Bear is not ready to board the Primary Care Mother Ship. Maybe we could have tried sleep deprivation and a low protein diet but he we didn’t have the time.

The End of the World As We Know It

The Future of Medicine, Uncategorized

Back to the Future

“So you want to hear how your old Grandpa lost his leg do you? I know what you’re thinking and no, I didn’t lose it in the Burger Wars. You’ve seen my old uniform hanging in the closet but by the time I enlisted…oh..had to have been the Summer of 2057… the war was almost over and what was left of the McDonald’s forces were either surrendering in droves or holding out at isolated food courts in places like Duluth.”

“I’m sure you’ve seen the videos and learned all about it in school. I’m sometimes sorry I missed the action but I guess it was for the best. I’m not sure I had what it takes to kill a man, even if he was one of those bloodthirsty pan-frying monsters. (‘Happy Meal’ my ass.) I remember watching thousands of them being marched to the prisoner of war camps. But you know, other than their yellow and orange uniforms and their Iron Clown insignia they looked pretty much like our boys so maybe they really didn’t commit all of those atrocities.”

“Anyways, I spent my enlistment in the Burger King Reserves guarding a couple of Arby’s and a Wendy’s off of Exit 54. In fact, I never even fired my weapon except for a couple of potshots at a burning Golden Arches in front of a McDonald’s down the road that had taken a direct hit from a lard-seeking cluster bomb.”

“My leg? Oh. Well, one day…must have been twenty years ago…I started having chest pain and figured I needed a doctor…”

“What’s a doctor, you ask? Well, I guess you kids have never heard of doctors. I suppose they don’t mention them much in the history holograms either. Let’s see…Well…Once upon a time if you got sick or injured you went to see a person called a ‘doctor’ who supposedly knew a lot about diseases and how to cure them. These guys went to school for years and years learning a bunch of essentially useless knowledge and then spent the rest of their lives rubbing it in our faces. Not to mention raking in obscene amounts of money. They were replaced by something called a Physician Assistant around thirty years ago.”

“I see some of you remember Physician Assistants or have at least heard your parents talking about them. They’re pretty much gone now, too. Same with Nurse Practitioners. If we weren’t going to let somebody with ten years of medical education strut around there was no way we were going to allow some wanker with only two years to get all big-headed either.”

“My leg? I’m getting to it. Patience.”

“So anyways I started having chest pain and since I wasn’t sure if it was my heart or reflux I thought I’d get it checked out at Cath-in-the-Box.”

“Never go through the hover-through. They fuck you in the the hover-through. If I could do it over again I would have gone in but I was in a hurry. I’m pretty sure they got my order right. It’s pretty hard to yell symptoms into that stupid clown microphone and the questions they asked me were kind of garbled but I figured, hey, it’s a just a heart cath. Their sign says ‘One Billion Stented.’ They do them all the time. It’s not rocket science after all. Just squirting some dye into an artery and inflating a balloon. A monkey could do it.”

“So I get to the window and pay (I think it was 50 bucks which was a lot back then), turn on the radio, stick my leg into the slot and figure I’ll be out of there in five minutes. The pimply-faced kid who took my symptoms is running around putting in arterial sheaths which is not very difficult to do and why they have minimum wage high-school kids doing it. I could tell he was having a little trouble and his “trainee” badge should have tipped me off because by the time he got to me…well…let’s just say his sterile technique left a little to be desired. At least the assistant manager did the actual procedure. He was probably pretty good at it because, as you know, Cath-in-the-Box sends all of their managers to PCI-U for an extensive six-week training course. He maneuvered the C-arm into my car and six minutes later I had a stent in the ‘big artery thing that, like, runs down the front of the heart.’ I felt pretty good and my chest pain was gone so I figured that the a little bit of melted plastic on the dash was a small price to pay. The little “dosimeter” toy that came with the PCI-combo said that my radiation dose was within normal limits and the complementary EKG thingy showed the usual incomprehensible squiggly lines which the assistant manager believed were normal but wasn’t really sure.”

“A couple of days later I notice that my groin was all red and puffy and, to be perfectly honest, I felt like crap. They always stiff you on on the antibiotics at Cath-in-the-Box so I figured I’d get some from the corner Jiffy-mart. A pharmacy, you say? I see we’ve got a budding historian here. Of course I didn’t go to a pharmacy. Even back then they were all gone. As if I needed some over-educated pharmacist with his pricey doctorate-level education and thousands of useless and expensive facts giving me high priced pills with fancy Latin names. No thank you! The last Pharmacist died of old age at Suburbia Village a couple of years ago. (You know, it’s that replica of a small town from the early 2000’s where people dress in period costumes and work at authentic jobs from the turn of the century. Remember how we took you kids there a few Ramadans ago and Jimmy got sick on Slurpees?)”

“So they have a couple of good antibiotics there. I picked Panabx because it has a good blend of antibiotics and I don’t think I’m allergic to any any of them. I like their jingle, too:”

“Panabx, Panabx,
Drip, fever, sepsis got you in a fix?
Need somethin’ that’ll do the trix?
Then you need Panabx!”

“And then they had all of the good-looking topless girls running through the woods. Come on, I’m sure you’ve seen the commercial on the holoscreen. It’s the one set to the tune of that really cool, old Kevin Federline song.”

“Anyways, my leg kept getting redder and redder and I started having alternating chills and fevers. ‘Oh great,’ I said to myself, ‘you’re septic again, just like after your self-service splenectomy over at Organs n’ Things.’ I tried a few more brands of antibiotics but I’m pretty loyal to Panabx so I thought if one dose wouldn’t do the trick, I’d try eight. Your Uncle Scott who’s a professor over at Marshal Mathers University (or M and M) suggested that I might need to get it amputated but he’s a rich frickin’ psychologist. What did he know?”

“Turns out he was right. I staggered over to Home Depot and I’m afraid I might have been a little incoherent from the fever because their little orange aprons looked like the MacDonald’s uniforms and I might have tried to eviscerate a couple of the associates with a cordless laser saw. After they tackled me to the ground and duct-taped my arms to my sides, I sat through a health-improvement seminar taught by a really nice guy named Chip. I bought the Black and Decker Limbzall and your grandma and Uncle Scott held me down while the take-out anesthesia took effect. When I recovered my leg was gone and everybody looked at me like, ‘Dude, you were so acting like a retard.'”

“I wrote a nice letter to Cath-in-the-Box and they refunded my money which was nice of them.”

“Would a doctor have done a better job? Maybe a little better but it’s not worth all of the questions, testing and general screwing around that they used to do to get your money. What my past medical history or whether I smoke has to do with anything is beyond me. They never waste your time with that kind of thing at Cath-in-the-Box or Bile, Bowel, and Beyond which is why medical care is so cheap, quick, and affordable nowadays. If I have another heart attack I’ll probably just get a quick thrombolytic out of the vending machine. They have a whole bunch of them down at the Stroke-o-mat. It’s pretty safe if you just read the friggin’ instructions on the front of the machine.”

Guest Blogger: Mrs. Panda Bear

Uncategorized

My Better Half

(Every guy has one great love. A woman who sets his heart beating by her beauty, her wit, and her charm. She doesn’t have to be Rebecca of Sunnybrook Farm but some combination of her looks and personality strikes you like a thunderbolt the first time you meet her. Unfortunately, not every guy marries this girl and many end up settling. I was lucky enough to trick the perfect girl into marrying me and I have never regretted or been unhappy for a single day in our marriage, probably because our relationship is built on a long friendship before we started dating. Not that I didn’t want to date her the first time I saw her, you understand, but I guess I had to grow on her.

Of love, that over-rated and poorly understood emotion, respect is the better part and without it love would be little more than thinly disguised contempt. Such a relationship would be an unhappy one if it even lasted. I am lucky, on the other hand, to have the respect of my wife and I work hard to justify it. I owe her a lot. Simply because I wanted to, she allowed us to trade a good career, financial security, and stability for the instability and poverty of medical school and residency. She has given up a lot. The last move was particularly hard as we had just unpacked, it seemed, when we began the long and arduous process of selling the house and moving again.

So I don’t ask for a lot of sympathy from my wife and she is confident enough in our love and our friendship to give it to me straight, especially when I am tempted, like most interns, to feel a little sorry for myself. Residency is hard but there are harder things, particularly the sacrifices of a stay-at-home mom taking care of four young children. Those of you who are married with kids need to keep this in mind as you slog through medical school and residency. It is a grind for your wife, too. My wife periodically had to set me back on track last year when, as you my faithful and tolerant readers know, we had suffered the setback of scrambling into a specialty and a hospital which I disliked intensely.

In this article, Mrs. Bear identifies one of the worst aspects of intern year as well. -PB)

It was that time of the month. Those first five days when he felt awkward, inadequate, and really, really dumb. Every month of intern year he suffered from the anxiety and low self-esteem of being the new kid on the block. As for myself, being a stay at home mother of four children, I have many many things on which to concentrate my efforts. I depended on my husband to fulfill his commitment to his residency program so that I could take care of the home front. So why did he exhibit anxiety and depression?

Children often have temper tantrums when their routine is changed. I suppose these children grow up to be adults who flourish in a stable consistent environment. I knew our son had difficulties with changes in his routine. I wasn’t expecting my husband to have these difficulties as well. In fact, he was the last person on Earth I would have expected to have difficulties with switching from one rotation to another during intern year. When I knew him as a Marine, he was always on the go. He never owned more than what would fit into one sea bag. I cringe at the things he tells me he and his Marine Corps buddies threw overboard as they approached shore.

My job as his wife metamorphosed to include therapist. I sat on the couch and listened to his stories about his day. They were a lot more interesting than what I had to say about our children’s bowel habits (which are very important to a mother). It was several months into intern year that I recognized a pattern. During the first week of a new rotation he was almost miserable. As the days went by he became more and more confident. About the time when he felt he had become a useful team member it was time to begin a new rotation.

When one member of the family is suffering, the whole family suffers. It became my purpose to remind my husband that everything is new and “they” didn’t expect him to know anything when he started a new rotation. With this realization he became more at ease with his ever changing schedule thus becoming a better human being to live with.