A Whole New Era

I realized the other day that up until now, I have held a very privileged title: Student. The Student is a special person who is nurtured in a loving relationship with the Teacher, another special individual. The Teacher gently admonishes the Student, guiding the Student toward lofty goals of learning and achievement, mollycoddling and spoonfeeding the whole time. This type of learning starts in pre-K and for me, didn't end until the end of the second year of medical school.

In the third year of medical school, though my title still says "Medical Student", my rank has changed. I am no longer a person to be taken by the hand and guided to knowledge. Nay, I am now a peon of the lowest sort. Nurses groan when they see me coming: "Oh Jesus no, it's a medical student. Lord save us!" Interns ditch us at the slightest excuse: "I can get my work done soooo much faster if I don't have to answer all those damn questions and correct all the mistakes those idiots make." And attendings? Ah, the attendings. See, an attending is not just a "Teacher". No, an attending is a Doctor. Their job is to heal the sick and cure the dying, not to deal with the lowly 3rd Year Medical Student, who is like a fungus growing between the attending's toes.

I had an attending pimp me through a case in the OR mercilessly--I said "I don't know" to the very first question, and he just kept going. One of the questions I actually answered correctly, and he said "No! It's BRCA-2, not BRCA-1!" If I were still the hallowed Student, I could go look up the answer (which I did anyway) and email the Teacher, saying "Sir, I found this information in regards to our discussion earlier." As I am a 3rd Year Medical Student, I would do the former under pain of death (or a Failing grade). Instead, I swallow hard and say "Thank you for that information, sir."

At our clinic, we have a nurse practitioner who covers 2 shifts a week. To be a nurse practitioner, you have to have at least an RN (minimum 2 years), possibly a bachelors (4 years), and a Masters in Nursing (2-3 years). In addition, this particular NP has a PhD (I know this because the initials are on her coat). Let it not be said that I have no respect for the position of Nurse Practitioner--these people work a long time to achieve that title.

However, this particular NP at our clinic is a real work of art. Since she has a PhD, she introduces herself as "Doctor [X], the Nurse Practitioner". I'm not even sure what that means, and I'm in a health profession; patients routinely look bewildered at this introduction and mostly call her "Doctor" (which seems to be her goal). When a patient calls me "Doctor", I correct them; she does not.

I probably wouldn't have noticed the above quirk, but this same NP seems to delight in raking 3rd Year Medical Students over the coals. She barged into a patient's room while I was in there, grabbed a prescription from me and said (loudly) "You wrote the prescription wrong!" She fixed the error with a flourish and handed it back to the patient's dad, saying "I'm sure glad I saw that it was wrong!" In the hallway, she lectured me on the error I had made, using the word "wrong" at least 6 more times, just in case I didn't hear it the first time. I'm wrong a lot. I know this. I don't mind being told that I'm wrong. I just prefer being told in a nice manner, preferably very quietly behind a closed door so that NO ONE could possibly overhear. Seriously, there was no reason to loudly inform the patient's father, more than once, that I, me personally, no one but me, had written that prescription wrong. (Also, the error in question was very small, and the prescription would most likely have been filled, correctly, no questions asked as written.) In one afternoon, this NP managed to loudly correct each of us three lowly 3rd Year Medical Students. At one point, I literally waved a chart in her face for five minutes while she and the other ladies swapped stories about their weddings. HEL-lo, it's Friday afternoon at 3:30, you ladies can socialize later, but if you don't see my patient soon it will be after 5 when ALL of us get to leave (things move slowly at this clinic).

My grade from my last surgical rotation is still pending. By "pending", I mean that apparently the faculty who graded me have not turned in my evaluation yet. Nor have they turned in the evals for the students who rotated through the first month. If these were "Teachers", the people in charge of turning in grades would fuss at them--"I know you're busy, but your job includes turning in those evals." Instead, these are "Doctors", "Surgeons" even. No one would dare suggest that these noble persons were not doing their jobs or were not doing enough work.

Someday, I'll be one of them. I'll be a Doctor. Then you will all bow to me as to a God.




The Fine Print: Naturally, this was satire. Fiction. Lies, all of it, lies. Except the parts that weren't. I've had lovely attendings and very few assholes. I just wanted to attempt to be funny. Laugh! Laugh, damn you!

Fuckers. If you won't laugh then all 2 of you who read this blog should go the fuck away.

I'm sad

And when I'm sad, I want to withdraw. If my hubby didn't live here, I'd probably not even see him, unless he came over to see me. I was picturing my life if he'd stayed in DC, and I can't imagine that I'd be dating anyone, because when I get down I see everything in my life as down. I don't like writing when I'm down, because I like to be happy and funny in my writing, and I just can't do it right now.

My dad tried to call a little while ago, and I didn't hear the phone ring, but I didn't want to answer it. I feel so fatigued that everything takes effort, including picking up the phone. Answering the phone means sounding chipper and pretending that I feel fine and I don't have that kind of energy at the moment.

One of the things that I can always find joy in, no matter how I feel, is food. I'm not a thin depressed person; when I'm down I eat (more than normal, which is saying a lot). This morning, we kept our Sunday morning tradition of eating out for breakfast, and today I had huevos con nopalitos--eggs with cactus. It was incredibly tasty--I was surprised.

Sometimes I think I ought to turn this blog into a food review, since I talk about food so much (and eat so much of it), but that wouldn't work: I'm a "rut" eater. I have 1 or 2 dishes at each of my favorite restaurants that I can always count on, and I usually stick with those. So if you didn't want to hear about the cheese ravioli at Olive Garden, the chicken fajitas at Taco Cabana, the vegetable enchiladas at Mama Ninfa's, or the nugget 6-pack at Chick-fil-A, then my reviews would be useless.

I think I eat the same things over and over again for several reasons. 1, I know they're always good. 2, what if I ordered something that sucked? And here's the last, 3, life is too short not to eat what's good. I am really bad about delaying my gratification when it comes to food. Maybe it's because my career and school lives have totally been delayed gratification, so I need to indulge myself in something NOW. Maybe I just have ZERO willpower (well, definitely). For whatever reason, I cannot deny myself food if it's present. It's why I don't buy Double Stuf Oreos anymore--I can't stop myself from eating the whole damn package (and then groaning for hours with the stomachache).

Damn, now I want some Oreos.

TOOL!!!!!!!!!!

So my hubby and I are going to go see Tool tonight!!!! I am so excited. This will be my second time to see them, and my 5th time to see Maynard perform live. Woo! I'm officially a groupie.

I use rock concerts as a way to recharge. I haven't had anything to report about my current clinic because all I see are abused and neglected children. On Sunday, at my godson's christening, I cried during the service, just thinking that there really are parents out there who love their children, who feed them and bathe them and don't abuse them in any way, parents who treat their children like precious gifts. I kind of feel toxic, like I've ingested something bad.

Some people go to church; some people go to gardens or temples; I go to rock concerts. I scream and jump and flail my arms and head bang and sing at the top of my lungs and lose my voice and let the music control my body--and I feel a little better about the world. This Tool concert is going to be like a visit to a spa or a Swedish massage; I'll be tired and sore afterwards, but a little tingly and thoroughly relaxed. And smelling a wee bit more like cigarette and marijuana smoke (I swear it's not mine!) than I would at a nice spa, but that's beside the point.

Bad News

1) Iran is becoming a nuclear power. It's not quite there yet, but the country is definitely trying, and is very defensive about letting anyone come in and look around. The UN specifically told them not to do this, and threatened them with sanctions. Where are the sanctions now? European nations, including Russia, are afraid to administer sanctions at this time. Why? Because of America. They're afraid we're going to go invade Iran and start yet another Middle Eastern war of attrition. (New York Times, 09/02/06)

Way to go, America. Our invasion of Iraq, under largely false or trumped-up charges, has almost guaranteed that Iran, the scarier country with a larger inferiority complex, is going to make a bid for nuclear power. Good job on keeping down that Axis of Evil, there, Georgie.

2) A study in France found that women without any prenatal complications had 3.6 times the risk of dying after caesarean section compared to vaginal delivery. The deaths came from anesthesia, infection, and blood clots. (Obstet Gynecol. 2006 Sep;108(3):541-548)

Now, even at 3.6 times the risk, this is still a very small risk--the study included 65 deaths out of over 10,000 births. However, we need to study this very closely. In 2004, 29% of births were C-section, compared to 20% in 1996. More and more of these are elective C-sections by first-time moms who want scheduled births or have elective scheduled inductions, which increases the risk of having a C-section (the key word here being elective). This is frightening. These are young, healthy women choosing dangerous procedures for essentially "convenience" reasons.

Mind, the rate of C-section has risen not only because of elective procedures but for several other reasons: 1) obese women have more prenatal complications which necessitate C-sections. As our obesity rates climb, so will the attendant C-sections. 2) Doctors are afraid of lawyers who sue at the drop of a hat and recommend C-sections more frequently. 3) Multiple births following fertility procedures often require C-sections. 4) Women who have had 1 C-section often require later births to be C-sections as well.

I just wonder how "convenient" some of these women would find a C-section if they knew they had an increased (yet still small) risk of not going home to raise that baby.

(Note: I have friends who have had C-sections for medical reasons. I'm not referring to you. Nor am I trying to lay all the blame on the women who want elective procedures--there are still real live doctors performing these procedures, knowing the risks, after all. I think our culture has encouraged this mindset, and we all need to evaluate these risks fairly and change our minds together.)

3) Texas Family Code 261 ties clinic funding to mandatory physician reporting of child abuse, including "sexual indecency with a child". According to this law, "an acceptable affirmative defense for abuse as defined in the Penal Code §21.11 (sexual indecency with a child) may be that the actor was not more than three years older than the victim; and of the opposite sex [emphasis mine]; and the actor did not use duress, force or a threat against the victim at the time of the offense."

Okay, so a 15 year old boy who sleeps with a 15 year old girl (assuming this was consensual and not coerced) has an affirmative defense against abuse; yet a 15 year old girl who sleeps with a 15 year old girl has NO affirmative defense, and this action is considered abuse under Texas law, and must be reported as such to Family Protective Services or the police.

This is clearly discriminatory. If a 15-year-old heterosexual couple can "consent" (it's not really consent since they're minors under 17) then a 15-year-old homosexual couple should be allowed the same protection under the law. If you're going to report one, you should report the other; or you should not be required to report either.

4) Under this same law, physicians are required to report to the authorities if a minor (under 17) requests a pregnancy test or tests positive for an STD. So, we're not required to tell the kid's parents about this treatment, but we have to tell the authorities?? What are the authorities going to do, arrest the kid for trying to obtain health care?

These laws were originally passed as a "rider" on funding legislation for the state health department. Since then, if you are a minor seeking treatment at Planned Parenthood, they hand you a form when you walk in delineating what may or may not be reportable; you have to sign to receive treatment. So either 1) kids are lying or witholding information when they receive treatment or 2) they're leaving and not receiving treatment.

As with the homosexual law, I believe that when these kids are afraid you'll call the police to tell them they're having sex, these kids will then NOT TELL YOU what they're really up to. I don't think this is discouraging teenaged sexual behavior; I think this is discouraging teenagers from receiving health care related to that behavior. If a 15-year-old male who is homosexual and sexually active cannot tell you, his physician, that he thinks he might have HIV because his male partner does, then he won't receive treatment or testing. If a 16-year-old girl thinks she's pregnant and can't come to the doctor for a test, the doctor can't assess what risks she's taking or try to counsel her regarding safe sex, abstinence, or anything that would decrease her risk.


It's just a bad news day today.

He loves me!

I just found this quote in my hubbie's message board thingie:

"The best thing about being married to my wife is that I feel the same about her now as I did the day before we were married. Nothing between us changed, we simply now have the legal recognition and benefits to help us protect that which we have built. She is my family just as much as anyone I am related to... even moreso, I'd say, because we got to choose.

So, yeah, I like being married, too. :)"



Wow.

New Obsession

So if you don't own the 30 Seconds to Mars CD you should, now. Go. Go, run, get it NOW. You can even listen to the songs on their website. Is it weird that I find their video for 'The Kill' oddly sexy, with Jared Leto wearing eyeliner screaming in his own face? Probably, but damn is it sexy.

I start Peds tomorrow, so hopefully I'll have more to report. All I've done the past week is, ah, nothing. Now, we're watching the Emmys, but they're in some boring-ass "the writers of reality-news-comedy shows that I don't have the time to watch" awards, so I figured I'd share my love for the new singing Jared Leto with all of you. You can think the tribute to Aaron Spelling for this.

It was bound to happen sooner or later...

Last night I was on call at [large hospital]. My trauma beeper went off around 2315 saying "Code 3 LF ETA 15 18 yo M MVC extrication Int G3 S76 P164", telling me that a code 3 (serious trauma) was arriving by helicopter in approximately 15 minutes; the patient was an 18 year old male who was in a car accident, had a prolonged extrication from his vehicle, was intubated, had a coma score of 3 (on par with a cadaver), with a low blood pressure and high pulse. Oh, boy. I happened to be in the OR at the time, watching the vascular surgeon repair a bleeding arterial leg wound. The upper and lower level residents and myself rolled on the trauma.

I enjoyed the sound of my clogs on the hard floor, marching purposefully toward the ER. When I got there, I took off my white coat, put on a lead apron, topped it with a clean gown, put my stethoscope around my neck and got my trauma shears ready. I usually do this quickly, because the ETA's on the beeper are horribly inaccurate. Once dressed and ready, I sat on a stretcher and shot the shit with the residents and nurses. Since this one was serious, 2 respiratory therapists were there with a ventilator; an ER doc was there with the ultrasound to perform the FAST (a quick check for abdominal bleeding); 2 X-ray techs were standing by with the X-ray machine and multiple blank films; several EMT students were hanging around, hoping to glean some experience; at least 3 nurses were in the room ready, with others waiting outside the shock room door. After all the fuss, we sat around for 10, maybe 15 minutes, just kicking our heels in the air, ready to go.

It's almost an electric current in the air when the stretcher appears. Everyone leaped to the ready as the helicopter crew wheeled in the patient. They transferred him to the trauma stretcher and things started to fly. The helicopter crew was hollering out the history and vitals as the residents and attending physicians started the ABC's: Airway, Breathing, Circulation, the primary survey. "Patient was questionably restrained, driver, his car was T-boned by a large truck/semi on the passenger side." The RT's began to establish a better airway and hooked him up to the ventilator, multitudes of lines and BP cuffs and EKG monitors and pulse oximeters were attached, a Foley was placed, IV's and central lines were started, and an oral-gastric tube was passed to decompress the stomach. The ABC's work like slightly sticky but well-worn machinery: everyone has a job, and they do it, but it's noisy as hell, and there's the occasional tripping over used syringes (not needles!) on the floor or the curse as yet another IV infiltrates. I mostly hung back after cutting off his undies, noting how thin he was, how small, how young, how helpless.

His blood pressures started to drop, so we started running in blood alongside the fluids. Multiple X-rays were obtained, showing large pneumothoraces on both sides, so the resident and the attending each placed a chest tube. Blood started coming out of his mouth and OG tubes, so suction was applied. Xray techs were frantic, the FAST doc was frantic, the resident was hurrying to place a subclavian central line, and I tried to stay out of the way, yet be available to run errands (a pair of sterile gloves, some gauze, some tegaderm, a chest tube kit). The FAST was negative, yet his pressures continued to drop, stabilized only momentarily by the addition of more blood and fluids. CT scan or belly washout? wondered the attending. He opted for belly washout, which is how I found myself going from holding a liter of lactated ringer's solution over my head to crouching on the floor to let the belly fluid drain back in. We got his BP up to 100 systolic and decided to take him to the CT scanner, which was next door. We added a body-warming device because his temperature dropped to 94. Sometime while waiting to go to CT, the resident noticed that the patient's pupils had become bilaterally dilated and fixed, or "blown"--a sign of serious neurological injury, possibly fatal. He put out over 1/4 a liter of fluid out of his chest tube in about 30 minutes, all of it blood. He also continued to bleed out of his mouth, sucking blood in and out of his ventilation tube every time they bagged him on the way to CT.

In the scanner, his pressures dropped into the 70's again, and we opted to leave off some of the less pertinent exams and just get the basics: CT head, CT chest/abdomen/pelvis. The head CT showed diffuse subarachnoid hemorrhage, intraparenchymal hemorrhage and edema, and possible uncal herniation (hence the blown pupils and continued coma scale of 3). We grabbed all the IV's, the ventilator, the warmer, and the O2, and wheeled him back to his room.

I think it was on arrival back in the shock room that I began to notice the steady trickle. I wasn't fighting the EMT students for a position anymore, I wasn't tripping over the Xray techs anymore, nurses were no longer yelling at me to get out of the way. The room was clearing out; we were down to 6-7 people. The blown pupils had sounded a warning note, but the CT ushered in the next movement. Neurology said there was nothing to do. He also had less than 1/2 his lung capacity open due to massive pulmonary contusion and hemorrhage. Once back in the shock room, he failed to oxygenate on the mechanical ventilator, and had to be continuously bagged. He'd received 8 units each of red blood cells and plasma. The attending went out to talk to the family; I heard at least one person suggest "kidney donor?" I frantically wiped his face down with alcohol swabs and towels, because the family came in to see him shortly thereafter. We had covered up most of the tubes and lines, we'd cleaned her face, but there was no disguising the bag-mask ventilation, the blood bubbling up the bag, the tear-stained eyelashes, or the utter silence from the one person in the room who we wanted to make noise. Her daddy told him he would pray for him and they left, silent, dry-eyed. We rushed him up to the trauma ICU, where they continued to ventilate by bag.

Up in the ICU, the acting chief resident came up with some wild plans: since he had no clotting capability left, order factor VII to correct the coags, then neuro would see her again. Put him on a special ventilator to force O2 into her lungs. Keep bagging as long as possible if the special vent didn't work. The residents and nurses in the ICU looked at him in disbelief. "For real?" one asked. "He's got blown pupils, no movements, no reflexes, and you want us to do what?" The chief took no for an answer, so the staff got to work. Walking away, the chief said "He's going to die."

I went to the cafeteria with the residents after leaving the ICU. I ate a Mrs. Bairds cinnamon roll and tried not to cry in front of them. Then I went to my call room, got into bed, and couldn't sleep. Were they still bagging? How long would his parents keep it up? Was it possible he'd recover? I would think, what a waste of effort, and then I'd be so ashamed. What if it was my daughter or son? I'd want extravagant measures taken before I was told it was over. However, I couldn't help but feel it was a waste of many things. I also couldn't get the sight of his youth out of my mind, his strength and delicacy. What a waste of a life, and it wasn't his fault.

At morning report today, we were told the patient "expired". His family decided to withdraw care. Officially, he is my first patient that has died.

I didn't cry until I got home.