I talk about poo a lot. Which is okay because in general surgery talking about poop is constant. And when you are on GI surgery it's even more prevalent. So, most conversations about poop don't particularly shock me. Until earlier this week when a progression of conversation has had me in hysterics every time I think about it.
It all started when my co-intern and I were sat down eating lunch together on Tuesday. It's rather rare for co-interns on the same service to actually get a chance to have a meal together so maybe the thrill of it all got to us and that's why this conversation happened. BUt whatever the reason it's really too much of a gem for me to keep to myself.
So, here is how it all went down. We were talking about the upcoming holiday, thanksgiving. And he had been going on for days about how much better enjoying a thanksgiving meal would be if he could have a foley catheter for his pee and a rectal tube in for his poop. "I'd never have to get up. I could just eat and drink ALL day." Then he said that it would just be convenient to have the rectal tube in all the time. It would save him a half hour every day, at least.
At this point I had to stop him and ask him what he meant by half on hour, at least. And he explained that his favorite time of day was when he came home, got completely naked and took a 30-45 minute poop. I started laughing . . . he continued talking. First of all, he wanted me to know that he doesn't poop naked at the hospital. And it was also important that I know how he keeps himself occupied during this time "it's not computing, it's compooping," he said. When he brought up how useful smart phones for occupying the time while he poops I was laughing so hard I literally burst a vessel and got a nose bleed.
Now, I was convinced that my co-intern was some kind of freak but he swore to me that this is normal male behaviour. Lucky for me I'm in surgery so my whole team is guys. Which meant that right before rounds we had a little pow wow about pooping. And I discovered that the 3rd, 4th and 5th year residents on my team all have various bathroom activities to keep them occupied while they poop. Two of them are on the same side as my co-intern and enjoy a nice naked poop. But my chief (the 5th year) doesn't understand pooping naked. He's afraid he would get cold, but he does enjoy pooping sans pants.
And, then I asked a question which would start a topic of conversation I'd never even imagined possible, "is there anything you boys won't do while pooping?" The general consensus was eat, until our third year brought up something that I'm sure has only ever happened to him but is hysterical none-the-less. "Sometimes," he said "I eat something with a particularly delicious smell and then when I poop a few hours later it smells exactly like that." At this point he stopped and thought about what he was saying while we are all looking at him like he was crazy. "McDonald's chicken nuggets are the best example I can give you. Sometimes when I poop out chicken nuggets I take a little whiff and I get hungry again, for chicken nuggets." And then as were dying with hysterics he did a little pantomime of him eating chicken, sitting down for a poop (with his phone) and then taking a smell and licking his lips in anticipation of another round of nuggets, "it's a vicious circle."
It took a good ten minutes to recover from that conversation and we still giggled out way through rounds. But the kicker was the next morning when our chief walked in and told us about he had been lying in bed alone while his wife was in the other room and he was thinking about chicken nuggets and started laughing uncontrollably. To the point that his wife had to come and check on him. Now the thought of our chief lying in bed laughing out loud while thinking about someone pooping naked while texting and wanting chicken nuggets is just about the funniest things I've ever heard. And I never would have heard about it if I hadn't been a surgeon.
11/27/10
11/26/10
Hospital for the holidays
I was driving home from work yesterday and I decided to go via the main road in our small university town. I've driven down this road dozens of times at all hours of the day and night but yesterday was surreal. Everything was closed, not a soul was in sight. There were wet leaves swirling in the wind and rain pelting dark windows. It looked like a modern day ghost town. For me, the weirdest thing was that hospital wasn't dead. Yah, it was a little short-staffed but all the lights were on, the beds were full, there was the gentle rush of noise and activity at every nurses' station. But outside the world had quietly retreated into their homes to be with their loved ones on Thanksgiving.
Having done my clinical rotations in New York I never fully appreciated how odd it is that the hospital is awake on major holidays. Because, as we know, New York never sleeps. So, yesterday was a bit alarming for me. The juxtaposition of activity inside the hospital and stillness outside was something I had never really been faced with before. And I suddenly realized that I work in a place that time doesn't touch.
I've definitely been in the hospital before and glanced up at an analog clock on the wall and been uncertain of whether it was AM or PM. But I thought that was more because of how I tired I was. But in all reality it doesn't matter if it's 3 PM or 3 AM . . . the hospital is still going. It doesn't matter if it's Thanksgiving or Christmas or July 4th. The hospital stays open. I think there is something noble about that.
People take it for granted that their local ER will be open whenever they need it. But what about the people working on thanksgiving day. What about their families and friends and loved ones? Well, for the time that you are the hospital you don't think about all of that. You focus on the job you have to do, you get your work done and then head home. Much like any other day. And for me, this Thanksgiving was very much like that. I went in, rounded, discharged 8 pull, placed wound vacs, pulled drains, inserted tubes. And then I went home. I had a headache so I spent my thanksgiving nursing that and giving thanks that I'd gotten out early and would be heading home the next day.
What really got me was all the people I hadn't discharged who would be spending thanksgiving in a hospital bed eating hospital bed watching hospital television getting cared for by people that would probably rather be elsewhere. In fact there was one lady who got admitted the night before thanksgiving. She was a transfer from another hospital. They'd run out of things to do for her so they called up my attending and asked if we would take a look at her. She was weak and tired when we walked in yesterday morning but all she wanted to know was if shed be eating turkey with her family. Even though she hadn't been able to keep down a bite for days.
Anyways,I just finished my rounds for today. So I'll be driving to my parent's house. Where I'll be getting a proper thanksgiving dinner. I'll be leaving my beeper and ID on my kitchen table and I'm going to spend serious time drinking, relaxing and spending time with my family. But, while I'm away the hospital will keep moving forward. The 8 patients I left on the GI surgery service will have changed, some will be better, some will be worse, some discharged and some newbies. Because that's the nature of the beast.
http://www.youtube.com/watch?v=poKiom33nCE&feature=related
. . . a little thanksgiving celebration scrubs style . . .
Having done my clinical rotations in New York I never fully appreciated how odd it is that the hospital is awake on major holidays. Because, as we know, New York never sleeps. So, yesterday was a bit alarming for me. The juxtaposition of activity inside the hospital and stillness outside was something I had never really been faced with before. And I suddenly realized that I work in a place that time doesn't touch.
I've definitely been in the hospital before and glanced up at an analog clock on the wall and been uncertain of whether it was AM or PM. But I thought that was more because of how I tired I was. But in all reality it doesn't matter if it's 3 PM or 3 AM . . . the hospital is still going. It doesn't matter if it's Thanksgiving or Christmas or July 4th. The hospital stays open. I think there is something noble about that.
People take it for granted that their local ER will be open whenever they need it. But what about the people working on thanksgiving day. What about their families and friends and loved ones? Well, for the time that you are the hospital you don't think about all of that. You focus on the job you have to do, you get your work done and then head home. Much like any other day. And for me, this Thanksgiving was very much like that. I went in, rounded, discharged 8 pull, placed wound vacs, pulled drains, inserted tubes. And then I went home. I had a headache so I spent my thanksgiving nursing that and giving thanks that I'd gotten out early and would be heading home the next day.
What really got me was all the people I hadn't discharged who would be spending thanksgiving in a hospital bed eating hospital bed watching hospital television getting cared for by people that would probably rather be elsewhere. In fact there was one lady who got admitted the night before thanksgiving. She was a transfer from another hospital. They'd run out of things to do for her so they called up my attending and asked if we would take a look at her. She was weak and tired when we walked in yesterday morning but all she wanted to know was if shed be eating turkey with her family. Even though she hadn't been able to keep down a bite for days.
Anyways,I just finished my rounds for today. So I'll be driving to my parent's house. Where I'll be getting a proper thanksgiving dinner. I'll be leaving my beeper and ID on my kitchen table and I'm going to spend serious time drinking, relaxing and spending time with my family. But, while I'm away the hospital will keep moving forward. The 8 patients I left on the GI surgery service will have changed, some will be better, some will be worse, some discharged and some newbies. Because that's the nature of the beast.
http://www.youtube.com/watch?v=poKiom33nCE&feature=related
. . . a little thanksgiving celebration scrubs style . . .
11/20/10
The sick role
I've been remiss in posting. I know. I'm sure all 5 of my readers are seriously bummed by this. I've been on the lower GI service this month. Which is pretty much colorectal surgery . . . but for us at my hospital we are the IBD (irritable bowel disease) specialists. The vast, vast majority of our service is made up of patients with ulcerative colitis or chron's disease. For those of you that didn't go to med school these are disease that affect the bowel causing cyclic waves of diarrhea and constipation. They can be painful, uncomfortable and life altering. But, they don't kill you. Well, they might be a contributing factor to your death. But your life expectancy isn't much altered as long as you have close medical/surgical care.
A little back story on chron's vs ulcerative colitis. Ulcerative colitis is by far the more benign of these two disease processes. As the name implies UC is limited just to the colon. Which means that by removing the colon you can cure the patient. Of course this means the potential of a life long ostomy and serious changes in your diet and bowel habits. Not to mention possible post-operative complications that could require more hospitalizations. But, yes the course is much better than Chron's.
I'm not really sure the exact reason why they call it Chron's. It's probably named after some old doc somewhere who first described it. That's how most things get there name, but I think that Chron's is an apt name for this disease. Because it turns young people into bitter old people long before they should be. The thing with Chron's is it's not limited to the colon it can actually affect the entire intestine and even extra-digestive organs. It goes through the full thickness of the bowel wall so you're more likely to get fistulas. It's also a granulumatous disease. But the kicker is that every time you go into someone with Chron's all you can do is a stop-gap repair. Because this person's bowel is not normal and every manipulation causes a secondary problem. But, it's not like we can just leave it alone because all those fistulas and abscesses and granulomas have to be dealt with.
So, now all of you out there are thinking that you'd rather have ulcerative colitis, and maybe you are right. I think I would. But I don't want you thinking that UC is an easy disease. Post-op complications like fistulas and abscesses can occur any time you manipulate the bowel. And these can become more of a problem then the original colitis. And either way, whichever process you are battling you are no longer able to poop normally. And with that comes a certain amount of psychosis. I'm not kidding about or exaggerating this fact. Not being able to poo regularly or at convenient times or just into a toilet makes you crazy. I want you to pause and think about having to be in a place that allows you to go to the bathroom 10-15 times a day. Or living with near constant nausea, even vomiting secondary to the need to poo or constipation. Or having your fecal matter hanging in a bag off your abdomen. Now that you've thought about that I think you can imagine why you wouldn't be quite right in the head.
These patients have astronomic levels of anxiety, they are often paranoid, co-dependent, ritualistic. Not to mention the fact that most of them are bitter and often times mistrusting of those in white coats. But, I think the saddest thing is that most of these symptoms onset while people are still in middle and high school which means that their child hood is destroyed. It's really hard to make friends when you're in and out of the hospital. Or if you're the kid that's always running to the bathroom. And what if one day you can't control your bowels and you have an accident? Try living that one down.
So, when doctors talk about the "sick role," we are talking about patients exactly like this. They've gotten used so used to being sick that they just can't figure out how not be. For them being in the hospital is actually a comfort. They know that they are going to be taken care of, that there symptoms are understood, that they can get medications that instantaneously makes them feel better. IV drugs will do that. And so we see people malingering and we have patients freaking out about not getting there dilaudid exactly ever 2 hours. These patients have such a large psychiatric component to their illness that often times you are treating that more than there actual bowel complaints.
It's hard as a surgeon to wrap your head around that sometimes. We can't cut out psychosis. We can't take a biopsy of crazy and send it to pathology to have it staged. Psych meds aren't something we are used to prescribing either. Most of us read the sex chapter in our psych books for laughs and giggles and then ignored the rest. I was always a little more interested in it and even toyed with the idea of going in to psych. For a fleeting moment only. Because the inability to fix people would have driven me crazier than my patients.
One of my favorite ladies on the service a woman with long-standing chron's who is on IV fluids at home because her ostomy puts out so much that she can't keep herself hydrated. She also does a little cocaine in her spare time. Which means that when she comes to the ED, which happens monthly, it's always a special treat. She's also always sick. Her electrolytes are usually out of wack. Her kidney numbers are usually sky high and she'll get admitted. Then, when she is in the hospital she does the crazies. Pouring food/liquids into her ostomy bag. Hoarding food off her trays and piling it up in the shower, which she doesn't use. Visiting with other patients and recommending medical therapies that have worked on her before. She exhibits ritualistic behaviour in her room when she doesn't realise she's being watched.
And she's really just the beginning. You have the woman who swears carrots came out of her vagina the day after we took down her rectovaginal fistula. The 19 year old girl with a gastric tube, a nasal tube, an ostomy who somehow managed to retain 2.3 liters of urine in her bladder, all with her belly ring in place. A lady who was taking enough pain medications to tranq an elephant and wouldn't drink water because the fish poop in it. And our fine gentleman who had his own name tatooed around his ostomy site. The woman who came to the OR with a note taped to her belly saying "make it quick, Obama needs my vote in 2012." Yup, they are all crazy. They are all so used to being sick they can't function without it. But, honestly, they are my favorite patients so far.
Also, a little treat for you . . . the poo song from scrubs. http://www.youtube.com/watch?v=pnIk0npINiE . . . this isn't strictly true in all other aspects of medicine but on GI medicine we spend a lot of time worrying about poop so I've been humming this a lot lately.
A little back story on chron's vs ulcerative colitis. Ulcerative colitis is by far the more benign of these two disease processes. As the name implies UC is limited just to the colon. Which means that by removing the colon you can cure the patient. Of course this means the potential of a life long ostomy and serious changes in your diet and bowel habits. Not to mention possible post-operative complications that could require more hospitalizations. But, yes the course is much better than Chron's.
I'm not really sure the exact reason why they call it Chron's. It's probably named after some old doc somewhere who first described it. That's how most things get there name, but I think that Chron's is an apt name for this disease. Because it turns young people into bitter old people long before they should be. The thing with Chron's is it's not limited to the colon it can actually affect the entire intestine and even extra-digestive organs. It goes through the full thickness of the bowel wall so you're more likely to get fistulas. It's also a granulumatous disease. But the kicker is that every time you go into someone with Chron's all you can do is a stop-gap repair. Because this person's bowel is not normal and every manipulation causes a secondary problem. But, it's not like we can just leave it alone because all those fistulas and abscesses and granulomas have to be dealt with.
So, now all of you out there are thinking that you'd rather have ulcerative colitis, and maybe you are right. I think I would. But I don't want you thinking that UC is an easy disease. Post-op complications like fistulas and abscesses can occur any time you manipulate the bowel. And these can become more of a problem then the original colitis. And either way, whichever process you are battling you are no longer able to poop normally. And with that comes a certain amount of psychosis. I'm not kidding about or exaggerating this fact. Not being able to poo regularly or at convenient times or just into a toilet makes you crazy. I want you to pause and think about having to be in a place that allows you to go to the bathroom 10-15 times a day. Or living with near constant nausea, even vomiting secondary to the need to poo or constipation. Or having your fecal matter hanging in a bag off your abdomen. Now that you've thought about that I think you can imagine why you wouldn't be quite right in the head.
These patients have astronomic levels of anxiety, they are often paranoid, co-dependent, ritualistic. Not to mention the fact that most of them are bitter and often times mistrusting of those in white coats. But, I think the saddest thing is that most of these symptoms onset while people are still in middle and high school which means that their child hood is destroyed. It's really hard to make friends when you're in and out of the hospital. Or if you're the kid that's always running to the bathroom. And what if one day you can't control your bowels and you have an accident? Try living that one down.
So, when doctors talk about the "sick role," we are talking about patients exactly like this. They've gotten used so used to being sick that they just can't figure out how not be. For them being in the hospital is actually a comfort. They know that they are going to be taken care of, that there symptoms are understood, that they can get medications that instantaneously makes them feel better. IV drugs will do that. And so we see people malingering and we have patients freaking out about not getting there dilaudid exactly ever 2 hours. These patients have such a large psychiatric component to their illness that often times you are treating that more than there actual bowel complaints.
It's hard as a surgeon to wrap your head around that sometimes. We can't cut out psychosis. We can't take a biopsy of crazy and send it to pathology to have it staged. Psych meds aren't something we are used to prescribing either. Most of us read the sex chapter in our psych books for laughs and giggles and then ignored the rest. I was always a little more interested in it and even toyed with the idea of going in to psych. For a fleeting moment only. Because the inability to fix people would have driven me crazier than my patients.
One of my favorite ladies on the service a woman with long-standing chron's who is on IV fluids at home because her ostomy puts out so much that she can't keep herself hydrated. She also does a little cocaine in her spare time. Which means that when she comes to the ED, which happens monthly, it's always a special treat. She's also always sick. Her electrolytes are usually out of wack. Her kidney numbers are usually sky high and she'll get admitted. Then, when she is in the hospital she does the crazies. Pouring food/liquids into her ostomy bag. Hoarding food off her trays and piling it up in the shower, which she doesn't use. Visiting with other patients and recommending medical therapies that have worked on her before. She exhibits ritualistic behaviour in her room when she doesn't realise she's being watched.
And she's really just the beginning. You have the woman who swears carrots came out of her vagina the day after we took down her rectovaginal fistula. The 19 year old girl with a gastric tube, a nasal tube, an ostomy who somehow managed to retain 2.3 liters of urine in her bladder, all with her belly ring in place. A lady who was taking enough pain medications to tranq an elephant and wouldn't drink water because the fish poop in it. And our fine gentleman who had his own name tatooed around his ostomy site. The woman who came to the OR with a note taped to her belly saying "make it quick, Obama needs my vote in 2012." Yup, they are all crazy. They are all so used to being sick they can't function without it. But, honestly, they are my favorite patients so far.
Also, a little treat for you . . . the poo song from scrubs. http://www.youtube.com/watch?v=pnIk0npINiE . . . this isn't strictly true in all other aspects of medicine but on GI medicine we spend a lot of time worrying about poop so I've been humming this a lot lately.
11/6/10
Specialization cut short by drinks.
So, a lot has happened since I last wrote to you. I've finished with Vascular surgery and I'm one week into lower GI surgery. I think I've written to you enough about all things vascular. It was not an easy month for me. Not because the hours were hard, and I even saw the humor in most of the patients. But, the medicine just wasn't for me. Right now, though, in the abdomen, I feel like I've returned to my happy place.
This has got me pondering on how young doctors pick their specialties. It's often said in med school that the professors can tell what specialty you are destined before just by meeting you. The nerdy ones with poor people skills often end up in specialties like radiology or pathology. It's always the geeky guys that are forever quoting journal articles that lean towards medicine. The kids that just quite pick what they are interested in lean toward family medicine. And the rough and ready guys that are always looking for their next adrenaline rush end up in the ED. The surgeons are the ones that are too cool for school. I could keep going on with the stereotypes. Tell you about the ladies the pick OB/GYN and the sometimes super creepy, too nice guys that go for it as well. But, you know all these things. Most of these stereotypes are quite intuitive. My question is about how one picks their subspecialty.
In this day and age being a generalized doctor is a death sentence to your practice. Everyone wants a specialist. We used to joke in med school that we would specialize in something obscure like the pinky and make a mint because people the world over would come to use for their pinky troubles. And we could charge double, even triple because we were the only one in the world. While that is a bit extreme it does have a nugget of truth. Specialization is the only way to survive.
So, now that I've picked surgery how do I pick a specialty?? We spend our first year rotating through a different specialty each month. We meet with an assigned mentor and we really should know what we want to do by our second year. But, it's a hard decision.
Ummmm, I'll finish later. I only just got home at 6 and I have tomorrow so I'd decided to just sit in and veg, write to you guys. But then a couple of my co-interns called and we've decided to grab some drinks since none of us have to work tomorrow. I'm going to wear make up. And fancy jewelry that dangles. Oh My God. It's been so long.
This has got me pondering on how young doctors pick their specialties. It's often said in med school that the professors can tell what specialty you are destined before just by meeting you. The nerdy ones with poor people skills often end up in specialties like radiology or pathology. It's always the geeky guys that are forever quoting journal articles that lean towards medicine. The kids that just quite pick what they are interested in lean toward family medicine. And the rough and ready guys that are always looking for their next adrenaline rush end up in the ED. The surgeons are the ones that are too cool for school. I could keep going on with the stereotypes. Tell you about the ladies the pick OB/GYN and the sometimes super creepy, too nice guys that go for it as well. But, you know all these things. Most of these stereotypes are quite intuitive. My question is about how one picks their subspecialty.
In this day and age being a generalized doctor is a death sentence to your practice. Everyone wants a specialist. We used to joke in med school that we would specialize in something obscure like the pinky and make a mint because people the world over would come to use for their pinky troubles. And we could charge double, even triple because we were the only one in the world. While that is a bit extreme it does have a nugget of truth. Specialization is the only way to survive.
So, now that I've picked surgery how do I pick a specialty?? We spend our first year rotating through a different specialty each month. We meet with an assigned mentor and we really should know what we want to do by our second year. But, it's a hard decision.
Ummmm, I'll finish later. I only just got home at 6 and I have tomorrow so I'd decided to just sit in and veg, write to you guys. But then a couple of my co-interns called and we've decided to grab some drinks since none of us have to work tomorrow. I'm going to wear make up. And fancy jewelry that dangles. Oh My God. It's been so long.
10/21/10
GTFO . . . Getting The Fuck Out
Most people look forward to vacations and breaks. But not like interns. Man, we literally live for them. They are the ONLY thing that keeps you going. As interns we work 80+ hours a week. Get only 4 days of a month and only 3 weeks off in the year. So when we go on vacation it's a big damn deal. I got all my vacation at the beginning of the year. And that is not ideal because it means no more than 2 days off in a row for the rest of the year. (Our year starts with June 24th and ends with the 23rd on the following June.)
So, I've been on vascular surgery the past few weeks and as I'm sure you've noticed it's been hellish. Well, tomorrow I leave straight from the hospital and take a plane to visit my family. We'll sit on the back porch, barbeque, play guitars, sing loudly, laugh, drink . . . and I will literally let all of this go. I will shut it out of my mind completely. I used to pride myself on my disturbing ability to compartmentalize the different parts of my life. Now, I seem unable to do that as well.
Being at the hospital as much as I am and having only other interns and residents to hang out with on my time off means this place has taken over my life. So, nowadays, even when I am off I still dwell. That's why this weekend is so special for me. I can let it go. There will be no subtle reminders. The familiar ambulance driving past a local restaurant. The dirty scrubs lying on my bedroom floor. The beeper clipped to my pants. All the people wearing the school colors of the university my hospital is affiliated with. But, the biggest thing is that I won't be with people that get it.
No one in my family wants to hear about the wound that I debrided at the bedside the other day that had the putrid smell only rotting flesh can have. And the story about the trauma patient whose blood I had dripping down my pants will just gross my family out. Also, they don't care about the hospital gossip and drama that we interns discuss ad nauseum. So, when I spend this weekend with my family I can put all of this in the furthest recess of my mind and get away.
I call it GTFO . . . Gettting The Fuck Out. It's aggressive and makes me sound kinda angry, maybe even a little closer to psychotic when it's coupled with the desperation in my eyes and the break in my voice. But, I need it. We all do. Guidos may have GTL, we have GTFO.
So, I've been on vascular surgery the past few weeks and as I'm sure you've noticed it's been hellish. Well, tomorrow I leave straight from the hospital and take a plane to visit my family. We'll sit on the back porch, barbeque, play guitars, sing loudly, laugh, drink . . . and I will literally let all of this go. I will shut it out of my mind completely. I used to pride myself on my disturbing ability to compartmentalize the different parts of my life. Now, I seem unable to do that as well.
Being at the hospital as much as I am and having only other interns and residents to hang out with on my time off means this place has taken over my life. So, nowadays, even when I am off I still dwell. That's why this weekend is so special for me. I can let it go. There will be no subtle reminders. The familiar ambulance driving past a local restaurant. The dirty scrubs lying on my bedroom floor. The beeper clipped to my pants. All the people wearing the school colors of the university my hospital is affiliated with. But, the biggest thing is that I won't be with people that get it.
No one in my family wants to hear about the wound that I debrided at the bedside the other day that had the putrid smell only rotting flesh can have. And the story about the trauma patient whose blood I had dripping down my pants will just gross my family out. Also, they don't care about the hospital gossip and drama that we interns discuss ad nauseum. So, when I spend this weekend with my family I can put all of this in the furthest recess of my mind and get away.
I call it GTFO . . . Gettting The Fuck Out. It's aggressive and makes me sound kinda angry, maybe even a little closer to psychotic when it's coupled with the desperation in my eyes and the break in my voice. But, I need it. We all do. Guidos may have GTL, we have GTFO.
10/18/10
Not another one
I was on call last night. I spent the day dealing with a patient who had either a ruptured abdominal aortic aneurysm or a small bowel obstruction. Clinically this man looked great. I really wasn't worried about him. My main concern was the nursing staff that just would not be helpful. I was sabotaged every step of the way. I wanted abdominal xrays they wanted me to order them at bedside (not useful). I ordered labs, they cancelled them.
I eventually got him down to the CT scanner after placing a nasogastric tube myself to run the contrast and the CT showed a ruptured aneurysm. We transported him to the ICU and then I went home and he went to the OR. I just accessed the hospital's electronic record keeping to see what had happened while I'd been at home catching up on my sleep. I noticed that his name wasn't on our inpatient census list. So I looked him up. It turns out he passed away.
I don't know what happened in the OR exactly. I know that the surgery was successful, they were able to repair his aneurysm. I know that he was extubated and then I know that he coded. Rationally, I knew that going o the OR and getting intubated would be very, very risky for this patient. He has a history of COPD and even when he sitting in bed with 2 liters of Oxygen he couldn't get his O2 sats above the mid-80s.
I'm wondering now what I could have done differently yesterday while he was under my care to have prevented or changed this outcome. Could I have been more aggressive in getting him to CT? Should I have transferred him to the unit sooner? Or was it all inevitable? All I know for sure is that I have another person on my list.
It sounds insane but I have this mental list of all the patients whose deaths I've been involved in. I try not to think about them. But sometimes there names and faces and problems will just pop up. I try to squash the guilt I feel. If I'd been a better a doctor, if I'd tried harder, if I'd done things differently. Even though none of these deaths were anyone's fault. If anything we'd done all we could to give them more time to live. I can't help but feel responsible.
These days medicine has become the art of keeping people alive well past when they should have died. Yes, sometimes we save lives of people who were not ready to die. But, in the case of this gentleman he was a well lived 70+ old man who had a lived a full and complete life. When his heart stopped he was still in the haze of anesthesia and probably felt no pain. His whole family had been with him for the past 2 days and I know he felt their love.
But, his family they weren't ready. I'm not ready and I only knew him for 30 hours. The daughter who sat by his bed all night and tried to understand all the things I was telling her. The wife who kept asking me why his face was so red. The grandkids who were playing in the waiting room. They are the ones for whom this is a tragedy.
I spent the whole of yesterday and last night telling these people that their family member was going to be okay. That there was nothing to worry about. That we had a close eye on him. That we were doing everything all that we could. And these weren't lies. But I think it was false help. All my platitudes made me feel better.
I've often wondered my seniors and attendings hedge so much when they talk to families. I've always prided myself on being direct with families and alleviating their fears. And 9 times out of 10 that's a good plan. Until something like this happens. I know it happens for all new doctors. And it's the only way to learn. But, right now I don't want the learning experience. I want that kind old man to be back with his family. I want to not feel like a liar. I want to have not let that sweet family done. I want to go to sleep and forget that this ever happened.
I eventually got him down to the CT scanner after placing a nasogastric tube myself to run the contrast and the CT showed a ruptured aneurysm. We transported him to the ICU and then I went home and he went to the OR. I just accessed the hospital's electronic record keeping to see what had happened while I'd been at home catching up on my sleep. I noticed that his name wasn't on our inpatient census list. So I looked him up. It turns out he passed away.
I don't know what happened in the OR exactly. I know that the surgery was successful, they were able to repair his aneurysm. I know that he was extubated and then I know that he coded. Rationally, I knew that going o the OR and getting intubated would be very, very risky for this patient. He has a history of COPD and even when he sitting in bed with 2 liters of Oxygen he couldn't get his O2 sats above the mid-80s.
I'm wondering now what I could have done differently yesterday while he was under my care to have prevented or changed this outcome. Could I have been more aggressive in getting him to CT? Should I have transferred him to the unit sooner? Or was it all inevitable? All I know for sure is that I have another person on my list.
It sounds insane but I have this mental list of all the patients whose deaths I've been involved in. I try not to think about them. But sometimes there names and faces and problems will just pop up. I try to squash the guilt I feel. If I'd been a better a doctor, if I'd tried harder, if I'd done things differently. Even though none of these deaths were anyone's fault. If anything we'd done all we could to give them more time to live. I can't help but feel responsible.
These days medicine has become the art of keeping people alive well past when they should have died. Yes, sometimes we save lives of people who were not ready to die. But, in the case of this gentleman he was a well lived 70+ old man who had a lived a full and complete life. When his heart stopped he was still in the haze of anesthesia and probably felt no pain. His whole family had been with him for the past 2 days and I know he felt their love.
But, his family they weren't ready. I'm not ready and I only knew him for 30 hours. The daughter who sat by his bed all night and tried to understand all the things I was telling her. The wife who kept asking me why his face was so red. The grandkids who were playing in the waiting room. They are the ones for whom this is a tragedy.
I spent the whole of yesterday and last night telling these people that their family member was going to be okay. That there was nothing to worry about. That we had a close eye on him. That we were doing everything all that we could. And these weren't lies. But I think it was false help. All my platitudes made me feel better.
I've often wondered my seniors and attendings hedge so much when they talk to families. I've always prided myself on being direct with families and alleviating their fears. And 9 times out of 10 that's a good plan. Until something like this happens. I know it happens for all new doctors. And it's the only way to learn. But, right now I don't want the learning experience. I want that kind old man to be back with his family. I want to not feel like a liar. I want to have not let that sweet family done. I want to go to sleep and forget that this ever happened.
10/16/10
List management
Census, rounding sheet, list, rounds report, these are all names we have for the list that we print out every morning with all of our patients on it. Each hospital and each service within a hospital has a different way of managing that list. Some hospitals list nothing but room number, patient name and diagnosis. Others are much more extensive. My hospital prides itself on our list. We like to think of ourselves as pioneers in this one bit of data recording. Our list contains not just the basics, but what meds they are on, their vitals, ins and outs and diet for the last 24 hours auto populates every time you print a new list. Additionally you can add in any procedures they have had or that are planned for. You can type up a plan, put in notes for the cross-cover intern. You can stick in random details about the patient that you don't want forgotten.
Basically, my hospital has a pretty sweet set up when it comes to the patient list. But that doesn't change the number one goal of any intern . . . KEEP THE LIST SHORT. Now, we have absolutely no say in who gets added on to our list. Ultimately that decision is for our Attending. And we can't discharge anyone that is still sick. But their are plenty of people who sit in hospitals for days, weeks, even months because that perfect storm to get them out just hasn't come together. Well, here is the checklist we go through before we send someone out.
1. Are they off of IV pain meds?
2. Have they been cleared by physical, speech and occupational therapy?
3. Can they continue their baseline activities of daily living?
That seems easy enough. But what about the chronic pain patient whose appendix we just took? Should we wait for days for them to get their pain under control or send them on their way? And patient with osteomyelitis who needs 6 weeks of antibiotics? Or the child with Leukemia who is going to need chemo every few weeks? Should these people just sit around the hospital? And how about the little old lady who just had a stroke and can no longer live alone? How do you get these people out?
I've worked at hospitals where these people will just sit in the hospital forever. Most of my fourth year rotations were about a month long. And I would start with a couple of patients who were in one of these awful situations and they would always be there when it was time for me to leave. I never really appreciated the art of getting someone OTD (out the door) until I started on Vascular Surgery.
For the last 2 weeks we've had a list hovering right around 20. Most of these patients were sick, 5 or 6 were ICU status we had another 7-9 that were intermediate level of care and the rest were floor patients. About half of whom were in the "just can't leave" column. So, rounding in the morning and being on the floor during the day has been a nightmare. It's even harder for the poor intern that's been cross covering for the last few nights.
And even though my co-intern and I were discharging anywhere from 3-6 patients a day we could not get the list below 17. And then, a break through! We finally, finally started discharging more patients then we were admitting. And by the time I left on Friday night we had 7 patients. SEVEN. We literally just made history for our service in the hospital.
Basically, this whole entry was just to brag about our superb discharging skills. Suck it vascular surgery!
Basically, my hospital has a pretty sweet set up when it comes to the patient list. But that doesn't change the number one goal of any intern . . . KEEP THE LIST SHORT. Now, we have absolutely no say in who gets added on to our list. Ultimately that decision is for our Attending. And we can't discharge anyone that is still sick. But their are plenty of people who sit in hospitals for days, weeks, even months because that perfect storm to get them out just hasn't come together. Well, here is the checklist we go through before we send someone out.
1. Are they off of IV pain meds?
2. Have they been cleared by physical, speech and occupational therapy?
3. Can they continue their baseline activities of daily living?
That seems easy enough. But what about the chronic pain patient whose appendix we just took? Should we wait for days for them to get their pain under control or send them on their way? And patient with osteomyelitis who needs 6 weeks of antibiotics? Or the child with Leukemia who is going to need chemo every few weeks? Should these people just sit around the hospital? And how about the little old lady who just had a stroke and can no longer live alone? How do you get these people out?
I've worked at hospitals where these people will just sit in the hospital forever. Most of my fourth year rotations were about a month long. And I would start with a couple of patients who were in one of these awful situations and they would always be there when it was time for me to leave. I never really appreciated the art of getting someone OTD (out the door) until I started on Vascular Surgery.
For the last 2 weeks we've had a list hovering right around 20. Most of these patients were sick, 5 or 6 were ICU status we had another 7-9 that were intermediate level of care and the rest were floor patients. About half of whom were in the "just can't leave" column. So, rounding in the morning and being on the floor during the day has been a nightmare. It's even harder for the poor intern that's been cross covering for the last few nights.
And even though my co-intern and I were discharging anywhere from 3-6 patients a day we could not get the list below 17. And then, a break through! We finally, finally started discharging more patients then we were admitting. And by the time I left on Friday night we had 7 patients. SEVEN. We literally just made history for our service in the hospital.
Basically, this whole entry was just to brag about our superb discharging skills. Suck it vascular surgery!
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