Revisiting an Old Issue, Not For the Last Time

My taste in residencies, and therefore careers, changes weekly, it seems. In fact, some of what I said in this previous post, I am now going to directly contradict here. So get ready!

My top two of the week:
#1: OB/Gyn--an excellent mix of outpatient clinic, inpatient NON-critical care, and OR time. Hours can definitely suck, but it's a field that is trying to work on this. It's also a field that tries to understand family time (the key word is *tries*; I didn't say *succeeds*). Residency: 4 years. Should not be difficult to get into residency, even with trying to stay here.

#A: Urology--Also a mix of outpatient clinic, inpatient non-critical care, and OR time. Residency would suck, at least for a while, but I'm willing to trade suckiness early for *hopefully* a better life later. Residency: 5 years. Extremely competitive; will be difficult to get in, even more so with trying to stay here. And pee? Not so bad, comparatively.

Possible Choices (in no particular order):
#1: Derm--Sometimes I feel like I'd be selling out, practicing "fake" medicine. Other times, I think, the victories would be small, but numerous, and there would be basically nothing life-threatening. Plus, lifestyle, lifestyle, lifestyle.

#2: GI--Could be satisfying to remove polyps and diagnose early cancers; not sure I'd want to manage cirrhotics, and I'm not sure I want to go through Internal Medicine to get there.

#3: Cardiology--Sometimes I think this could be really cool, sometimes I think this could be really boring. Plus, I am not so good at listening to heart murmurs. Plus plus, I'm not sure I want to go through Internal Medicine to get there.

#4: Infectious Disease--I still think bacteria are cool as shit, but I don't think ID docs really DO much. They show up, they say "Woo, cool bacteria", they recommend which antibiotic to use for how long, and they leave. Oh, and I think they do Gram stains. Ooh, ah.

#5: Internal Medicine--I get very frustrated in IM. I've also met the dumbest, most incompetent interns and residents in IM; my guess is because it's a sort of catch-all choice, a pathway to get to other specialties, and it doesn't really require a *positive* decision, only a ruling out of other specialties.

#6: Family Practice--Could be nice. Could suck. I hate tweaking meds every 6 months, so maybe not so good.

#7: Surgery--I love the OR, I hate the lifestyle.

#8: Emergency Medicine--I think it could be cool to be on the front line of medicine, but I think I would get even more cynical and bitter, and I don't really want to be that kind of person.

#9: Ophtho--Lifestyle, lifestyle, lifestyle. Except I do not find the eye so exciting.

Definite No's:
#1: Pediatrics--I'm a wuss about really sick kids.

#2: Anesthesia--I hate saliva. I have a kind of saliva-phobia, in fact. The thought of sitting in an OR while the guys on the other side of the curtain do the cool shit, sucking drool and phlegm out of someone's mouth... *shudder*.

#3: Radiology--Ugh. Only cool if you do interventional, and you have to do like 7 years of residency/fellowship to get there.

#4: Neurology--I realize this is surprising to most of you, but I hate neuro.

#5: Psychiatry--I love talking to people, and I think psychiatrists can do some good work, but it would drive me crazy. (Get it? Ha! I KILL me!)

Things I like:

• Being in the OR
• Sleep (negotiable)
  
• Doing small but gratifying things

Things I dislike/despise:

• Critical care: I really don't like being around long-term ICU patients. It reminds me of my fear of becoming such a patient.
• Rounding. Dear sweet jeebus, I HATE rounding.
• Incompetent colleagues.

And, some days, I just think I'm in the wrong profession. Sometimes, I envy my friends who have 9-5, M-F jobs. They get actual weekends! Weekends, people! And with a little luck, no one tries to drool on you (babies don't count)! And you don't see little containers of poo sitting on bedside tables (if you do, I don't want to know what you do for a living, but perhaps you should talk to Mike Rowe). I could go on, but I won't. You're welcome.

Breaking Bad News, Part II

Since making this post about the lecture we had on giving bad news, followed by a standardized patient encounter (in which I did fairly well), I've had lots more experience with it. I've seen a couple of different styles of news-giving.

My second medicine attending, Dr. C, was a heme/onc specialist. After examining her neck CT, I saw him tell a woman that her chemotherapy hadn't worked, that her tumor had continued to grow, and that it was now her decision whether to continue chemo or call home hospice. She cried. He repeated himself a lot, spoke calmly but empathetically; I believe he even held her hand.

My first call night on neurology, a man came in with a massive pontine hemorrhage. Virtually his entire brainstem was wiped out. I walked in to find the resident talking to his wife. We walked out to look at the CT, then we walked back in, the resident said simply "It's really bad. If there's anyone who needs to come see him, I'd have them come see him tonight, because it's possible he won't make it through the night." His wife cried. The resident apologized for giving her such news, and then we walked out.

My first neuro attending had to explain why he put a medical DNR on a comatose patient. He repeated himself over and over, because the family didn't understand at first. They thought we meant "we're withdrawing care", not "we won't resuscitate in case his heart stops again." Even though we were in the middle of rounds on a Saturday (and we wanted to get the hell out of there!), even though we were in the middle of a hallway, he continued the discussion until the family appeared to understand. They thanked him.

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There will always be bad news in medicine. I'm not sure I can be as *cool* as these doctors in the face of such raw emotion. Every time I see a radiology report with cancer, it's almost like I hear the "DUNH-DUNH" from Law & Order, or church bells, or some other very somber sound. I appreciate these doctors' examples, and I want to learn this skill. I just hope it's possible to learn this skill of communicating effectively and sympathetically, without either continuing to bring it all home, or going the opposite direction and becoming hardened by it all. I am inspired by these doctors, however, not to run from such things. All of them took it upon themselves to deliver bad news; none of them tried to run away, or shirk this responsibility. I admire that, and I think that if I can learn how to do this, I can be a good doctor.

On Call Again

Call II of neurology, and I'm sitting in the computer lab at the med school typing in my blog. Thus far, there have been no patients. I'd actually kinda prefer a patient or two (but not any more, ye gods of luck!!!) to this sitting, since I've been here since 6 am and I'm a little crankier than usual. I could be reading, but, you guessed it, I hate neuro.

Oddly, I hate neurology itself a leetle less after this rotation. At least on the stroke service, we do as much as possible, with the tPA and the aspirin. I do, however, despise the stroke service. Today, we got a new, (very nice) slower attending, and so we rounded from 0900-1200, broke for his conference + staff meeting, and rounded from 1400-1800. Seven total hours of rounding, followed by scut work. Whine, whine, whine. I whine even more because a) there are fourth years on our service, and you should hear THEM whine and b) most of my friends in this rotation are on services where they actually get weekends, or they don't work 13 hours a day. I almost cried with happiness when the coordinator told us we'd be switching with general neuro at the halfway point (and the general neuro kids were not too happy about it, which did not make me unhappy).

GGGGGRRRRRRRRRRRROOWWWWWWWWWWWWLLLLLLLLLLLLL!!!!!

Okay, I swear I'll quit whining now.

It's January now, and it's time for a new round of the game "What is TS going to do with her life?" I'll make a new post to follow...

Quote of the Day

My attending on the stroke service, asking about a patient from whom all life support had been withdrawn: "Well, I checked the obituaries for him this morning, but I didn't see him. I try to read the obituaries every morning to see which of my patients are in there."

Nicely sums things up, I think.

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The stroke service is an amazing dichotomy. Some of our patients recover fully and rapidly, leaving the hospital as healthy as they were pre-stroke. Some will leave for inpatient rehab to regain functions knocked out by the stroke. Some of our patients leave on stretchers, bound for "LTAC" (long-term acute care), to monitor ventilators, IV's, rehab, etc. Some don't leave, and some die quickly. For the 80% of patients who experience ischemic strokes, we can do a lot of things: tPA, keep blood pressure high to maintain perfusion, manage risk factors, etc. For the unfortunate 20% with hemorrhages, it's more a waiting game. Those patients can end up with ventriculostomies, on long-term ventilators, or worse.

I'm not as depressed by this service as I was by pediatrics, surprisingly. I feel like we're truly on the edge, "salvaging" those whom we can, trying to be compassionate to those whom we cannot. My attending does a good job, I think, of doing everything he can for those patients who have any chance of waking up, but conversely, not doing too much for those who don't. We've signed 3 physician's DNR's in the past two days. He's explained to the families that these patients already have severe brain damage, and that he feels it would be cruel to "bring them back from the dead" should their hearts stop, likely killing any remaining brain from global ischemia.

There's an element of selfishness to my train of thought. In really cliched terms, I've had to "confront my own mortality" while on these services. It's not really death I fear; it's pain, or losing my self. If I have to have a stroke, I'd want either a small one from which I can recover, or a huge one that just ends it all immediately. It's the middle ground that scares me. I could learn to live with paralysis, or restricted activity, or other disability; but I like being me. Usually, anyway.

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If you're ever in a coma, one way to assess your level of neurological functioning is to cause pain and observe the reaction to it. For example, pushing the handle of a tuning fork into a fingernail bed would ideally cause a patient to jerk their hand away. Rubbing knuckles deep into a patient's sternum would normally cause the person rubbing to get slapped (take my word for it, it really freakin' hurts). The levels of response (better to worst) are localization, withdrawal, posturing (flexor and extensor), and no response.

What could be worse than a sternal rub, or a fingernail press? My attending demonstrated today, on a patient whom we were assessing for brain death. "You see, you bring down the covers, take their nipple between your thumb and forefinger, pinch, and twist."

@#$@!!!!

The patient didn't respond. The audience (me), however, gasped, covered their chests, and turned away. Apparently, my visual response to someone else's pain is localization, which is appropriate.



And that, my friends, was a day's work on the stroke service.

Superman

Why is it that attendings no longer feel pain? We rounded for three hours this morning, and the med students are all griping about back pain and hunger. Our attending is totally impervious to such lowly physical needs, and only broke at noon for a conference, giving us an excessively long two hour break (which means we may not finish rounding until 6 pm or some such). I have a few theories as to why attendings are so stalwart:

1. Attendings have been standing on hard floors for so many years, they've killed all the nerve endings in their feet and back. I shall prove this with research, and call it "Attending Polyneuropathy."
2. Attendings are so passionate about their patients and medicine that they are able to ignore the pain in their feet and the growling of their stomach. If this is the case, I'm screwed.
3. Attendings have enough money to buy extraordinarily comfortable shoes that disguise themselves as ordinary fashion.
4. Attendings don't wear a white coat carrying 20 lbs of books, pens, tuning forks, etc., making them less accessible to gravity than the rest of us. I guess that the more you carry in your head instead of your pockets, the happier your spine is.
5. Attendings are rarely seen to eat or drink (unless it's coffee), and I've never seen an attending take a bathroom break (well, I did once on surgery, but the guy was 75+ years old). Perhaps they carry discreet battery-powered IV pumps for glucose and saline, and wear Foleys under their expensive clothing.
6. Perhaps the time difference is the answer. I arrived at 6:30 this morning to start seeing patients; my attending arrived at 9. Perhaps the extra hours of sleep he surely got have given him strength and fortitude to face the lumbar strain; certainly, eating breakfast later than 6 am would give him an advantage in making it until noon to eat.

I could be reading with my 2 hour break, but I'm not, because I hate neuro. I did, however, pick up a great new saying yesterday in lecture: "Time is Brain." You thought it was money, but I'm here to tell you, it's brain.

Good Book

For a very interesting read, check out I Am the Messenger by Markus Zusak. My aunt recommended it. It's set in an unnamed town in Australia; the protagonist is a "failure at life", a 20 year old cabdriver who starts receiving a series of anonymous messages he's supposed to deliver to perfect strangers. It's very funny, very moving, and totally unexpected; I loved it. It's technically teenage/young adult fiction, but whatever, I liked it.

I also recently allowed my husband to watch Firefly in my presence (which means I finally let him talk me into watching it). It was a sci-fi type show by Joss Whedon (maker of Buffy and Angel) that aired on Fox a few years ago, but was aired at different time slots out of order, and was canceled in its first season. Internet-types liked it enough that Universal Pictures bought the movie rights and made Serenity last year out of the story line and characters. Despite the fact that I was leery of the, uh, rather over-exuberant fan types, I guess I have to admit that it was a good show and movie. I'm kind of sorry the story is over now, actually. Yes, I'm admitting my geekiness publicly. It's just kind of hard to come out of that closet.

Back to Mythbusters (see above comment). I had intended to study tonight, but I hate neuro.

Stroke Team

Apparently, at our very large hospital, there's only one resident on call at night for neurology. One resident for seizures, one resident for strokes, one resident for kiddoes, one resident to bind them. The students on this neurology service take a kind of general call, seeing all kinds of patients. Therefore, even though I'm assigned to the stroke service, I saw two adults and one kid with seizures last night. The serious pontine bleed that came in, which should be on my service, I didn't actually get to see, because I was seeing the kiddo.

While I was in the EC, someone pulled the fire alarm. A piercing siren and flashing lights came on, and after a minute a recorded announcement played: "Warning: a fire has been detected in your area of the building. If you see any evidence of fire, please proceed to the nearest exit using the stairwells. Do not use the elevators." This played over and over, in between the ear-splitting sirens.

I found this message funny for several reasons. My whole life, I've always thought you were supposed to exit a building immediately when a fire alarm goes off. Countless fire drills in school have, well, drilled this message into my head. Last night's recording gives us the choice to evacuate, which both makes sense and doesn't make sense in a hospital setting. It's awfully tough to evacuate a large hospital full of patients, especially if it turns out to be a false alarm; however, if there truly is a fire, and everyone ignores the alarm, it becomes even harder to evacuate hundreds of people in a panic once they "see any evidence of fire."

There were actually a couple of lab workers who did evacuate the building through the EC. A hospital official laughed at them.