Scutmonkey Chronicles

A Bright Future in Scut

2007-03-23T05:30:00.001-07:00

What a difference a week makes...last week, I was scutting twelve to fourteen hours a day, wondering if match day would ever come, and if my sub-internship would ever end.

This week, I'm on a very relaxed research schedule, waiting for Fed Ex to show up with my residency contract, and just generally enjoying life. Not that I don't recognize that internship is right around the corner and going to hit me like bricks in the face, but right now, I'm just happy.

Match day was good to me. It would probably be unwise to say here exactly where I'm headed. I will say when I told my old advisor where I'd matched, his first response was, "Wait. Say that again." I've gotten that reaction from quite a few people and it always cracks me up.

I don't anticipate getting an Ivy League attitude any time soon, but my dog is way out of control already. I caught him on ebay late last night pricing berets, cigarette holders, and a rollneck dog sweater. Oh well, I guess I'll let him enjoy it.

"Got a Job, Don't Know Where Yet"...Like the Title of a Bad Country Song

2007-03-13T18:13:00.000-07:00

Got the official and cryptic National Residency Match Program Scrambler's Monday email yesterday. Nice subject line, by the way, if any NRMP people stumble on this post...keep the suspense up just a bit longer with that whole "Did You Match??" bit (and yeah, I did.)

Don't know too many other fields where it would be possible to say that you have a job but that you have no idea where yet. Not that it's a bad thing to know that my training is about to begin and my four year episode of hemmorhagic cash flow is about to end. Just a bit odd to still wonder where. Soon enough, I suppose.

My rotation mates and I were comparing notes the other day and are in agreement that four years is about the longest you can keep most of your stuff without it falling apart. Lab coats, case in point: you bleach them weekly for four years, and eventually, the thread starts to fail, the buttons fall off, and even the pockets separate from the main garment. (Pockets are a BIG DEAL, if you don't have them anymore.) My cell phone is currently missing four buttons on its dial pad, with a fifth and six ready to part company any day now. I could tell you a funny story about underwear waistband elastic giving out at an inopportune moment during interview season, but I'll save that for after the match is finalized, just in case...

I didn't enter medicine for the money, but it will be nice to have a paycheck again and be able to replace some of this stuff.

Things Looking Up and Geriatric Medicine

2007-03-10T06:55:00.000-08:00

Got new residents for the March schedule. Things are much improved since then. Goes to prove, you can be reasonably competant AND reasonably happy. Life is so much better when you can smile openly and even ask the occasional stupid question with no fear of reprisal.

Due to the location of my current hospital, 80% of our patients are over 65. This means an intense learning experience in geriatric medicine, and all that entails.

In general, I like working with older patients. They are usually pretty calm and understanding about the fact that nobody is going to be able to snap their fingers and put them back to their 20 year old state of being, whereas of the 40-60 crowd many seem to think that is possible and should in fact be the standard of care. Even if they have been eating nothing but baloney sandwiches and twinkies for the past several decades.

One thing I have learned about working with older folks is that you have to learn to take some of the things they may tell you with a grain of salt, but also not completely ignore statements that may sound a little "off."

An example: a patient on my service, who I'll call Miss Liz for HIPPA purpuses. Miss Liz is sweet and generally pretty with it for eighty-nine. She has also been a nursing home resident for the last eight years and has not driven a car for the past twenty.

Yesterday, I went to see Miss Liz and she told me with much excitement how, the night before, she had been involved in a twenty-car pileup in a neighboring town. She proceeded to relate details about live chickens running across the highway and a very handsome state trooper that seemed to be interested in Miss Liz, in a romantic way.

OK, so it was pretty clear that this didn't happen, at least the night before. But one thing it did tell me was that Miss Liz had made a sharp downhill turn as far as mental status in the twelve hours since I'd seen her. And that is important! As it turned out, she'd been on a very strong antibiotic (levaquin) that does strange things cognitively to older people. I had to go through a whole song and dance with her attending to get it changed, but when he came and saw her and saw for himself how different she was, he agreed.

A less educationally poignant but pretty funny geriatric story about another patient on the floor, Miss Jane. At ninety-four, Miss Jane has some interesting habits, things that when she first arrived we attributed to possible alzheimers. First thing in the a.m., she liked for the nurses to do up her hair in pigtails. While being wheeled through the hospital for her various tests, she liked to grab the butts of the male doctors and shout "Yoohoo!" As it turned out, Miss Jane is not senile. She just figures she should enjoy every day to the max. More power to her.

God Bless the Surgical Interns

2007-03-03T08:59:00.000-08:00

Two weeks into a four week medicine sub-internship. This is my last major hurdle towards graduation, and I’m excited about that, so I won’t waste a lot of time here on why the site of this rotation is not so hot for students, or why I would never choose to be a resident at this hospital.

Suffice it to say that too many of the parties involved have chosen misery as a lifestyle, and since in my view that IS a choice, I hold them responsible for their own despair and refuse to buy into it. Probably on some given day of my own residency I will myself be a miserable cur, but if I’m like this all the time, or I’m treating other people, i.e. med students, like crap, please just hunt me down and shoot me.

One bright spot that keeps me from focusing on this is the rapid approach of Match Day, less than two weeks away at this point. Sometime on March 15th I will receive an email alerting me to the location of my own indentured servitude. As I alluded to above, I’m going to try really hard to make residency a positive experience. I know it is possible because I’ve seen it done at other hospitals, and I’ve tried hard to assemble a rank list full of those places.

Another bright spot: the fact that although I am on a medicine service, for some reason almost all our interns will be going on to surgical programs. So, although they are under the dictum of the Medicine chiefs, they have amassed, through birth, exposure, or Gray’s Anatomy, enough Surgical Attitude to not take much shit when they have a say about it.

Case in point: the intern I was assigned to stand call with today. I showed up at seven with enough food and changes of scrubs for a hectic twenty-four hours. She had me round, write notes and orders, and then cut me loose. In her words, after a sixty hour week on a medicine service, I wasn’t going to absorb a whole lot following her around to check labs on a Saturday. (Also, although she was too polite to say it, I would probably have slowed her down in the process.)

How refreshing is that—the ability to call bullshit where it exists and send somebody home for a nice weekend?

Smallville

2007-01-25T19:31:00.000-08:00

Ok, in case I haven't mentioned it, I picked a specialty--psychiatry. Have been on many, many residency interviews and think I know where I want to do my indentured servitude. Now all that remains is to see if my top choice wants me. Provided I don't change my mind in the next three weeks and screw everything up...

According to the explanations from the match people, over 90% of applicants get one of their top three picks. So I should be ok. As long there is a paycheck and dental insurance involved, I can make pretty much anything work.

As for the Smallville reference, I was watching because my go-to Thursday night show (My Name Is Earl) turned out to be a rerun. The Smallville episode was sort of a psychiatrist-to-be's nightmare: Clark is wrongly institutionalized by the Luthers. A very authentic looking psychiatrist tells him that he is actually a paranoid schizophrenic, and goes on to reference his belief in super powers, an alternate universe, and a conspiracy against him. (Didn't hurt that the guy they got to play this doctor is a dead ringer for one of my professors.)

So Clark goes through a whole hour of complications, such as his mother being brainwashed and married to Mr. Luther, a roommate at the hospital who thinks he is a superhero from Mars, and the threat of some sort of mind erasing treatment.

Needless to say, there were many glaring differences between the depiction of mental health care in this show and in reality. For one thing, Clark's room in the instituion was unrealistically big.

Seriously, I have no real worries about mistakenly 302-ing Superman. But it was scary...that is how it must actually seem to be psychotic.

2006-10-26T14:01:00.000-07:00

High Class Problems and a Thousand Dollar Sandwich

2006-10-24T14:53:00.000-07:00

Strange things happen: Got back Part Two of the licensing exams, and it would appear that I had one, singular eight hour stretch this past August where my operating IQ was substantially above its norm. (And then went back down to gutter level). Ten hours after the scores came back, my phone started ringing, and some of the residencies I'd applied to "just as a joke, to see if they really do read the applications," were calling to set up interviews. Bizzarro world does in fact exist.

All this has caused a good but stress inducing change in my world view. Where I'd been all set to hunker down at the first residency near a beach that appeared to want me, now I've got options to consider. But Ivy League or no, the beach is hard to let go...

This is a high class problem. I could just as easily be gearing up for a costly and alopecia inducing retake of Part II. So, what I'll probably do is get in my beater-mobile, check these places out, eat their free lunches, and then make some decisions. What I'm telling myself is, pick the place that is the best combination of good education and happy residents. What might happen on rank day is I give in, either to the temptation of going to a big name place that will make me miserable, or to the most laid back gig I can find. But hopefully, there IS a happy medium.

As for thousand dollar sandwiches...took the "Practical Exam" part of the licensing gauntlet today. Due to the confidentiality agreement we all had to sign, all I can tell you about the exam is that the lunch was decent...turkey club rollup sandwiches and, the bonus, canollies for dessert. Even just halfway through the day most of us were at the point of adrenaline fuelled giddiness, so when someone blurted out "best thousand dollar sandwich I ever had", we all started laughing hysterically.

No, it's not that funny, but neither is shelling out a grand for a test with a 97% pass rate. Can anybody say "Why Botha?" Let's just hope there's no reversal of fortune on my IQ upswing that puts me in the bummer 3%...

A Humorous Aside

2006-10-04T14:44:00.002-07:00

Not much time to post, but had to get this up there:

I'm sitting in our sweatshop of a student lounge yesterday morning, chilling and doing chartwork, when this friend of mine starts stressing about one of our attendings who kind of mumbles, and how my friend might consequently have given one of his patients an inappropriate script.

Apparently, this woman came in with sinus congestion. My friend saw her and then presented the case to the attending in question. This guy is an old school dude we all happen to love despite his tendency to sometimes speak inaudibly. After my friend presented the case, the attending told him to write for a decongestant called Mucinex. At least, with the benefit of hindsight, that's what we think happened...

My friend happens not to be a morning person, and gave the poor woman a script for Metamucil, to be taken three tims a day. By the time he mentioned to the rest of us in the lounge how it didn't seem quite right for blocked sinuses, the attending had co-signed the prescription and the poor lady was long gone.

Hopefully she's not still going...

Public Service Announcement (Or, Don't Make Me Kick Your Ass)

2006-09-27T18:40:00.000-07:00

Just a short post today, a sort of public service announcement:

If you have kids, or are tangentially related to one, PLEASE take a few minutes to locate their vaccination records and put them away in a safe place.

Why, you ask? And why am I making such a big deal about it?

I'll tell you why. I've been doing a lot of unneccessary stabbing of kids with long needles. Kids whose dumbass parents lost their vaccination records. Kids who in order to start school have to begin the vaccination schedule from scratch, to the tune of four injections a visit, every eight weeks, for the better part of a year.

And then their dumbass parents wonder why these kids don't like doctors. If you ever, as an experiment, want to feel really, really evil, try explaining to a school age kid why they need to be turned into a human pin cushion, and then hold them down while you stick them repeatedly.

In a perfectly fair world, it would be the dumbass parents that get stuck. Maybe I could make it all a bit more equitable by punching them once in the nose for every extra needle their kid has to get. Guessing the state medical board, and the police, might have a problem with that, though.

Enough said.

Way Down Town in the Antecubital Fossa

2006-09-26T11:09:00.000-07:00

Writing this during a glorious, unexpected half-day off. Thank god for scheduling errors, right?

Began the afternoon with a leisurely lunch of Clif Bars and Diet Coke, gonna do a little catching up on the old blog and residency interview arrangements, and then it's Nap Time.

Or, considering that it's two p.m. and I'm not locked in a windowless exam room, attempting to stab an innocent, screaming two-year old with a long vaccination needle, or persuade a resistant lung cancer patient to give up the smokes, maybe I'm already asleep...?

Here's the layout of my fall: eight weeks of working in a very urban clinic owned by my medical college. Sort of a "finishing school" to make sure we can all handle the basics of operating independently before they sign off on us as intern material. In some ways, it's pretty cool--we see patients in our own exam rooms like residents would (although there is still a serious amount of supervision by the attendings). We give vaccinations, draw blood, even do minor procedures like irrigations and drainages. Sometimes the staff even screws up and calls one of us "Doctor" on the overhead pager.

Never in a million years did I imagine I'd get good at drawing blood; in the past I've actually gone to extremes to avoid it. I wasn't afraid of the blood itself--more the idea of sticking another person multiple times and not ever filling up the tube. Which is not fun for anybody involved.

I'm getting to the point where I'm decent at it, even with very large people and little kids. The secret, I think, is to visualize the anatomy inside the antecubital fossa (the fold at the inside of the elbow) and to go in very gently as you picture where the veins should be. While you're doing that, you've got to keep the patient super calm, (or restrained, if neccessary). Since you're never likely to be more than 1/4" from paydirt, if you yourself stay calm, a small adjustment one way or the other usually does the trick.

If all that sounds very competent and professional, honesty demands that I admit this technique was developed at the cost of about six gallons of sweat into the pits of my lab coat for about the first twenty draws I did.

For your entertainment, here's a link to two interesting sites about the history of phlebotomy. http://www.medicalantiques.com/medical/Scarifications_and_Bleeder_Medical_Antiques.htm
http://www.mtn.org/quack/devices/phlebo.htm

So next time you're in the process of being stuck by a bumbling, inept medical student, think about the items on this page (i.e. the "SCARIFICATOR"), how lucky you are not to be having bloodwork done in the sixteenth centry, and maybe it will make you feel better. Or not...

Time in an Urban ER

2006-08-04T12:06:00.000-07:00

Time flies when you're working night shifts, slogging through residency applications, and getting ready for boards, part deux. It looks from the record page of this blog that it's actually been three months since I've posted anything here.

An interesting three months...ditched my med school apartment (and insane landlord) in favor of a year "on the road" and all the adventure (and bad hospital and truckstop food) that entails. It's been fun, being unleashed on the world with no rent to pay and no kitchen to clean, but then again, it's gonna be nice to have my own place again next year, wherever that turns out to be.

The summer began with a month of shifts in an inner city emergency room. You may have heard in passing that there is a lot of bad heroin going around the East Coast. Not to imply by that description that there is "good" heroin, but this stuff is really bad, in that it is killing relatively young, healthy people. From what I've been able to gather, this particular brand of smack is laced with fentanyl, and/or coke, and/or speed, depending on your luck. (In case you haven't heard of fentanyl, it's a super-potent pain killing drug, usually reserved for surgical cases and cancer patients.) The problem with the fentanyl is that it seriously depresses a user's drive to breathe. That alone is killing people. Add to that the coke/speed, and you jack up the oxygen demand on the heart enough to crash almost anyone's ticker. Bad scene.

Another problem with this situation is that the standard line of questioning for a young patient presenting with chest pain is "Have you been snorting/shooting coke?" Nine times out of ten, if the person was actually doing the bad heroin described above, they have no idea there is more to it than meets the eye. Even in the rare case that the patient willingly 'fesses up at that point regarding the heroin, the ER staff is not neccessarily going to make the leap that it's causing the chest pain. (Not knowing this information doesn't drastically change an approach to chest pain of unknown cause, but it doesn't help.)

My other major memory of the ER is the tendency for good staff members to become pretty damned embittered. Because no one who presents to an emergency department can be turned away, far too many people use it for sore throats, pregnancy tests, and other BS reasons. One month was enough to make me a lot more skeptical than when I walked in, so I can imagine what a couple years or more does to people. It's a shame, because what ends up happening is that really sick people who walk in with vague complaints end up getting treated as malingerers and drug seekers. You can't blame the doctors and the nurses, but it's not a good situation for the patients.

Although this explanation is one sided, many staff members felt that hospital administrators use ERs as a cash cow, in that there is guaranteed cash flow from government reimbursements for the kind of uninsured, non-refusable ER patients I mentioned above. The ER docs I talked to thought the administrators were using these funds to prop up unprofitable programs in their hospitals and other pork barrel type stuff. You can imagine the kind of tension this created in the hospital. So, although I enjoyed some aspects of my time in the ER, I walked away grateful that it was not my life's dream to practice this kind of medicine.

The Nerve

2006-05-03T19:02:00.000-07:00

This month: Neurology, at Big Name Academic Hospital. So far, so good.

This is my first real elective. Why the hell then, you may be asking, did I pick something hard and not near a beach? Answer: I dig this brain stuff. Enough to think maybe this was a field for me.

Still dig it. Probably not the field for me, though. Nice people, smart people, but epitome of "in the box" thinkers. May as well have kept my engineering gig.

Case in point:

Ward team goes to see new patient, sent up to floor from ER with working diagnosis "erratic behavior, etiology unclear, rule out cardiovascular accident" (translation: dude acting strange, make sure dude didn't have stroke.)
Attending physician is brilliant clinician with many publications.
Team enters room, attending in lead. Patient hisses like angry cat, waves rosary beads, and threatens to piss on attending
Patient looks over ward team, consisting of Indian attending, Pakistani fellow, Russian cheif, Jamaican resident, and Mooncheese White student with name of undiscernable ethnicity.
Patient reads names aloud and accuses team of being "assasins from the UN".
Mooncheese White med student thinks to herself "Perhaps, just maybe, there is a psychiatric component to this gentleman's problems?"
Brilliant attending continues to treat as simple stroke. Because That is What is Written on the Chart...

Oh well, it's an interesting gig, not too tough, and my future patients, in whatever specialty I pick, are likely to walk into the office with a brain. Let's hope.

Human Hearts and Housecalls

2006-04-15T14:56:00.000-07:00

What a great month. Spent the last four weeks learning cardiology, soaking up an unexpected amount of knowlege while tagging along with an eccentric, wild, compassionate, and great doctor. (One of very few doctors I know of who still makes house calls.)

I did not start off this rotation with high expectations, because:

I eeked by in first-year "cards." One of those deals where you pick up your test in the dean's office and they give you "the look."
The course director of the rotation is a well-known hard ass, and I'm famously bad about people who get in my face.
The doc I was assigned to follow in the lottery had a reputation for being sort of eccentric. Not that I mind eccentric, but faced with having to pass Dr. Hard Ass's killer exit exam, this did not seem like an ideal setup.

Good thing I'm often wrong.

This experience was the diametric opposite of what happened first year:

I'd sit down to read the stuff, it would make sense, and I'd remember it. Even the EKGs started to fall into place.
The guy I rotated with explained his part of things in "very simple bear" terms that I got, and was very funny and entertaining to boot. Sometimes eccentric is a big plus.
On Monday mornings, when Dr. Hardass the Course Director would lock the twenty of us in a room and zing hardball questions at us, I'd do ok. (Although he still seems to not enjoy my sense of humor, but that's too bad. Especially now that I've nailed his exam. Nailed as in "honors." Put that in your Hard Ass pipe and smoke it...)

One of the most positive things about finishing this rotation was realizing that this shit is starting to sink in, and I'm as capable of applying it as anybody else. Another positive was the house calls with my preceptor. I saw some weird, shocking stuff, but learned a ton about putting compassion into practice by participating in these wild jaunts to take care of inner-city shut-ins.

Ok, I probably should not say "weird and shocking" without going into at least a little detail. Let me tell you about my first two housecall patients and let you use your imagination from there.

Patient One: widow of taxidermist. Every square inch of living room wall covered in animal cranium. Left to right: deer, deer, moose, bobcat, dear, elk. Live chihuahua in plastic crate, seeming to wonder if he is next. Shocked med student who shall remain nameless, dangerously close to unintentional bladder emptying after being sent to grab medicine case out of bedroom and coming face to face with black bear on hind legs.
Patient Two: seven-hundred pound man who has not left apartment in six years, and who earns living running mail-order porn business. (Yes ladies, he IS single...)

Enough said. Like I said, good thing I'm often wrong.

It Is What It Is...

2006-03-16T10:13:00.000-08:00

Done w/ i-med. Been there, done that, and got the vomit stains on my jacket to prove it.

Had a very strange en-masse exit interview with the aging program director and five other med students. Funny how different people perceive a situation in very different ways. I left the hospital with basically a neutral and more or less happy impression, having learned some good stuff, met some good people, endured quite a few indifferent and/or lazy people, survived one death threat and one attempted mugging, and found it all basically par for the course.

Of the five other students in the room, two were also sort of neutral about the experience, two were barking pissed off, and one claimed to have had an ecstatically good time that kind of left everybody else in the room with their eyebrows raised.

I don't think it's a coincidence that the three of us who found the experience more or less neutral all had paying jobs doing something or other before coming to med school. My hypothesis is that if you've worked for a living, you know that "baseline" for most people in most jobs means taking a lot of shite along with whatever satisfaction the job might bring. Anything better is icing on the cake, and that icing is usually what you scrape together for yourself.

Going right to med school out of college that may not be so clear. Thinking about myself at that same age, especially considering the school I came from, I also had expectations of the world that were not all that realistic. Nothing wrong with ideals, unless you're shocked that other people don't share them. And they almost never do.

So I was a little embarassed for my two classmates who were kind of screaming at this aging doctor who is the program director at this hospital (even though his stories about monkeys in Costa Rica really were of questionable relevance to our education...) I was wondering, have these people never been in a crappy situation before? Really?

As for the ecstatic kid, I'm not sure what his deal was. I think he was actually sincere. Or maybe he got into the pharmaceutical locker.

Round Ten: Cardiology. Should be a kick.

The Limits of Compassion

2006-03-07T13:56:00.000-08:00

Since beginning work on the wards last June, I have been dreading two inevitable occurrances. One: having a patient die under my care. Two: having a patient that I am not able to work with, to the extent that I have to sign off the case.

Number Two happened today (in the literal and figurative meanings of the phrase :)

From what I've been told, these things are inevitable, and more or less a matter of luck and numbers. Work with enough patients, and it's bound to happen. You're not supposed to take this personally, and I'm trying not to. Here's hoping that after a few hours at the gym and a nice stiff mochachino, I'll be successful at that.

This particular case ended with a rather unfortunate and unstable patient making bodily threats against me, that, considering her history, were simultaneously very funny and very scary. (It would make more sense if I could explain that history, but for privacy reasons I'm going to resist that urge and not get into the details.)

In general terms, I'll just say that whatever her motivation, the patient was angling for a certain diagnosis, a diagnosis that was not in any way medically supported. During the five days of her hospitalization, tens (if not hundreds) of thousands of dollars in tests were conducted, and the nursing staff was put through the wringer by this patients' nonstop antics.

By about day two of five it was starting to become clear that this patient might have an agenda other than getting well. The attending, residents, and nurses on the team had mixed reactions, from outright anger to guarded compassion. In any case, we were still obligated to meet the "standard of care" and run every possible test to rule out the condition in question. We did that.

As for my reaction to the patient during these five days, it at least began on the compassionate end of the spectrum. I think that first started to be strained on the afternoon when I was present in the patient's room when a friend came to visit her. As I was taking the blood pressure cuff off that patient's arm and getting ready to leave, she told her friend that we'd made a certain diagnosis. The patient knew at that point we'd definitively ruled that diagnosis out.

It was awkward, to say the least, for me to hear this because the patient knew I could hear her and we both knew the diagnosis had been ruled out. I'd like to think that even when I had decided in the logical part of my brain that the woman did not and could not have the disease she was insisting she had, I treated her with the compassion and respect any human being deserves.

I'm not sure that's completely true. Besides being present during the above exchange, I was also in the somewhat awkward position of hearing the frequent (but confidential) cries of "bullshit" from the attending and residents but still having to be present and respectful at the point of care. Realistically, there were probably moments when I did not live up to my good intentions.

The situation came to a head this afternoon. The results of the "definitive" test for the condition in question had just come in, and I called the two attendings involved to inform them of those results and ask how they wanted to handle things. As it turned out, one of the staff docs wanted the patient out of the hospital, ASAP, and asked me to start writing up the discharge papers. The other doc was hesitant, not so much about the results, but about how to handle the discharge without a knock-down, drag-out confrontation that might end in all of us being dragged into court, as this patient was tangentially employed by the healthcare system that owned the hospital, and, right or wrong, quite capable of kicking up a lot of dust. (As a matter of interest and record, most cases where it is later proved that a patient faked an illness involve people employed in the healthcare field.)

Apparently, the patient overheard parts of this phonecall and went into a rage. Shortly after I put down the phone, one of the unit nurses came by to inform me that the patient had made some very specific, and what at the time seemed rather funny threats against me.

A few minutes passed while I waited for the hesitating doc to call me back and the threat started to seem less funny. Even though this patient was not what you would call athletic, and I am in fairly good shape and recently managed to shake off a guy who tried to mug me in a parking lot, something about the overall behavior of this patient scared me. It scared me way down in the lizard part of my brain where logic just doesn't prevail.

I wrote everything down in the chart, had the nurse who had conveyed the threat witness it, and went downstairs to tell the resident and the attending. They agreed that things with this woman had gone too far.

In an odd way, we were all a little relieved: by making these threats, and being dumb enough to do it in front of a reliable witness, the woman had just given us carte blanche to hand her her walking papers and wheel her out the door. The nurses actually gave a little cheer on hearing their not-so-happy time with this person was coming to a definite end.

As for me, after being formally relieved of this person's care, I had the rare treat of leaving the hospital while it was still light out, and that made me very happy. Still, the whole situation makes me a kind of sad. I really do hope that it's in God's plan for that woman to find some peace. On the other hand, I'm selfish enough to hope I'm not involved in that plan.

Scutwork Revisited

2006-03-03T14:22:00.000-08:00

I am still a year away from possessing the title Doctor. However, with nine and one half months of rotations now under my belt, if there is one thing I now feel qualified to comment on, it is Scutwork. I will begin by saying that although the term Scutwork may come across as completely negative, to say that there is nothing of value in Scutwork would be incorrect.

As with most things, Scutwork is, in and of itself, neither good nor bad. It just is, and it just has to be done. And if you are a third year med student, it just has to be done by you.

Ok, so maybe it is painfully obvious that I stood two calls this week and am on the hook again tomorrow (Saturday). Oddly enough, I am not really all that resentful regarding my current work hours. Just resigned. And given the experience I now possess, I can say with some degree of confidence that even though I'm maxed out, this rotation is one of the better ones I have been on.

So I suppose what brought the topic of Scutwork to mind was a random encounter I had this afternoon, in the corridor of the generic med school I attend, with a friend who is in the class behind mine and who just set up her schedule for next year. It went something like this: Friend (wide eyed and painfully eager): Hey, I just signed up to do my XYZ rotation at PQR Hospital. I heard you were there. What can you tell me?

Me (sixty four hours into my eighty hour week, clutching a Diet Coke in one hand and a coffee in the other): Get out now. Or run away and join the French Foreign Legion.

Friend: Really? But that hospital has a great reputation.

Me: Yeah, and well they should--they spend all their money on PR. That swanky pen you're holding is all you'll ever get out of them.

Friend: So you mean, they'll kill me with scutwork? Was it the worst schedule you ever had?

Me: No, they didn't kill me. And no, not the worst schedule.

Friend: What, then?

Me (struggling to put into words the bag full of anger I had about this hospital, that I didn't know I had, until my friend asked me about it): Oh man, just don't go there.

So I got to spend the rest of the afternoon trying to figure out why, two months after I left that place, I had this unexpectedly vehement reaction to being asked about it. This is the conclusion I came to: the massive amount of *@it work I put in during that month was in no way balanced by the minimal amount I learned during that time. I was too dumb to know it then, but I do now.

Third year, is , some ways, a psuedo-economic deal you strike at each rotation site: I will provide X-amount of slave labor, and in return, you will provide Y-quantity of learning.

Sometimes scutwork itself is enlightening, but not always.

Some rotation sites are "honest brokers" in that there is a lot of teaching built into the schedule, and you will get a fair deal just by showing up and working hard, without every being forced to haggle for your enlightenment. (Enlightenment which you are also paying the yearly equivenlent of a luxury sedan to attain.)

At other places, it becomes painfully obvious that med students are nothing more than calculated components of somebody's business plan, and that the plan doesn't include teaching those white coat wearing revenue generators much of anything.

A student who takes a totally negative attitude toward scutwork is headed for trouble and disappointment. It is a simple fact of life that somebody has to copy down lab results, make calls to welfare agencies, and sometimes, lift huge patients on and off stinky bedpans.

I actually don't mind doing these things, most of the time. I've been a patient my fair share of times, and I know that when you are on your back and helpless, the last thing you want to deal with is a resentful, snarling medical staff. When this personal logic fails, I try to remind myself that the huge person who has to be lifted off the bedpan is probably somebody's grandmother. (Although my grandmother is not huge and stinky, if she were, I'd still want somebody taking good care of her, and not be giving her a lot of attitude about it. )

When even that fails, I corner the local resident (in the nicest way possible...yeah right) and subtly remind them that in exchange for the amount of grief I am taking off their hands, I should be getting some amount of teaching in exchange. Most of places and most residents do allow for some degree of negotiation regarding the balance between indentured servitude and learning.

As for my friend, who got an earful that she was not expecting, she had the good/bad/random luck to tap me on the shoulder on a day where all remnants of my (not too diplomatic on the best of days) conversational tact had been fully eroded. So regarding Hospital X, what I had not even admitted to myself just came flying out: they took advantage of me, and of all the other students who rotate through there.

They make cavegirl mad, and cavegirl not forget...

I-med Grand Rounds: Peewee vs. Doogie

2006-02-23T15:26:00.000-08:00

Four days into an internal medicine rotation. I'm enjoying it, even though I will definitely hit the eighty hour cap this week. My favorite part of this gig, so far, are the ER admissions. You get paged by one of the senior residents and told to go admit so-and-so in room-x, and you just never know what might turn up. A total crapshoot, my friends...

Today's gem was a 78 year old woman with a gangrenous toe. She and her daughter had already been to another emergency room in the city and signed out against medical advice when somebody mentioned that the toe might have to come off. Through the subtext of our exchange, it became clear that the daughter knew and fully accepted the likely outcome, but remained powerless to convince her mother of its neccessity. She was just playing along in hopes we would somehow admit her mother without anyone screwing it up by saying the "A" word (amputation).

Despite being left mostly paralyzed on one side of her body by a previous stroke, this lady was Feisty with a capital F. She nearly kicked to the floor the beefy surgical resident who made the mistake of conducting a "sensation check" on the rotten toe. A Kodak moment for sure, that woman's size nine foot planted firmly in that surgeon's gut. Although it was clear to all present that she was aiming a just a little bit lower...

Least favorite part of Internal Medicine? Grand Rounds. Let me tell you why. Grand Rounds, in theory, is meant to be this golden forum for the exchange of ideas; cases are presented for discussion, and ideally, there would then be this magnificent cross-pollenization between members from the varying subspecialties. In actual practice, Grand Rounds is frighteningly reminiscent of the trainwreck of a gifted-and-talented class I was forced to endure back in fourth grade: forty minutes (conservatively) of every hour are spent while the same four or five people to try to establish that they are the Smartest Person in the Room. The leading men at this particular hospital are an attending pulmonologist the residents call Peewee Herman, and an intern who is the Pakistani incarnation of Doogie Howser.

At certain points during these exchanges, I am sorely tempted to yank aside one or other of these jackasses and scream, "Look man, don't you realize you'd actually end up looking smarter if you stopped blurting shit out?" But, of course, I've never actually done that. Mainly because I am more or less content handling the situation the way I did back in fourth grade--sitting in the back of the room telling fart jokes.

Another thing I have noticed about this rotation: even on days when I manage to get home before dark, I am completely and thoroughly exhausted. I mean, noticeably more so than with other rotations. My theory as to why? Between the staggering amount of information we are required to process and the depth of emotion kicked up in dealing with the extremely sick patients who populate inpatient medical wards, even a very enthusiastic and very competent person would be bound to be tapped by day's end. (I haven't met that person yet, but nevertheless, I'm willing to bet they're as tired and crapped out as the rest of us by the time signouts roll around...)

Tomorrow: Friday night call in the ER. Guess I better go get some rest, Pilgrims, while the beeper's still behaving itself.

Surviving Surgery, The Sociology of Alpha Dogs, and a Revolutionary New Procedure

2006-02-21T14:23:00.000-08:00

Man, it's been forever since I've had time to update this blog. As of last Friday, I am officially done with my med school inpatient surgery requirements, and what a relief that is. (So much so that I decided to spend this weekend on the opposite coast, at a wedding reception in a biker bar. But that's a whole 'nuther story.)

Some of this finishing-up relief doubtless comes from navigating the last three months without suffering any of the really horrendous and embarrassing surgery rotation incidents you hear so much about--vomitting and/or passing out over the table, having an attending hurl instruments at me, etc. Not to say I didn't make a ton of mistakes--just nothing that will make me famous.

Photo of surgical procedure described below

The other part of the relief has to do with not just surviving those twelve weeks, but kind of enjoying them. Not that I'm a huge fan of sleep deprivation, runaway egos, or disposable hairnets, but it's always nice to leave on a good note. Suprisingly enough considering my initial ambivalnce toward all things surgical, a couple of the attendings I worked with tried to recruit me into the fold. Needless to say that was very flattering, and because of the respect I have for these doctors, I at least considered it. For several reasons, though, I don't think I'm going to take them up on the offer.

One reason is age. I'm about ten years older than most of my classmates. Although I'm pretty confident that I could successfully finish the five to seven years of training surgical training entails, where age really becomes a factor is the limited amount of time I could realistically expect to practice after completing training--fifteen to twenty years at most. I have not personally met any surgeons practicing past the age of sixy, although I hear that some do exist. Given that short career span, the sacrifices required might not make sense. Especially given that those sacrifices, for many women, include giving up any shot at a normal family life, which is something I still hope to experience.

Another (and perhaps more compelling) reason to wave off is the gut instinct that the field is not, in the long run, a good match for my personality. I suspect that at least some of the reason those attendings asked me to consider surgery has to do with the ability to put on a game face, endure physical discomfort, toss around lockerroom banter, and deal with alpha dogs. Those skills were honed while engaged in a previous career that, without getting into too many details, involved airplanes and blowing things up. Although in some ways that kind of work environment is comfortable and familiar to me, I'm pretty sure that in the long run I'd find it restrictive. (If you're reading this and half awake, you know I have a quirky side that I'm not good at keeping under wraps.)

In the course of weighing surgery as a possible path, I stumbled across a really interesting book by a Harvard anthropologist named Dr. Joan Cannell called "The Woman in the Surgeon's Body." Over the course of about ten years, Dr. Cannell spent time following thirty-four women surgeons through their workdays and talking with them about their experiences. Some of their most negative experiences, vis a vis sexism and social isolation, were eerily similar to things I went through during that aforementioned period of flying and blowing things up. Although I know I can handle those kinds of obstacles, the real question is, do I really WANT to?

I'm thinking no. If surgery were my one compelling goal in life, that sort of crap would be worth enduring. Ironically enough, if my time as a flygirl taught me anything, it's that being a happy, kind person is worth at least something. Furthering this point are two flygirl-to-doctor converts I ran into this week who decided, offers to prestigious surgical residencies be damned, they'd be most happy in Family Medicine. Maybe that's the kind of choice you can best make after you find out how little prestige has to do with being happy.

Now, on a much lighter note, the promised description of the aforementioned Revolutionary New Surgical Procedure.
A few Saturdays ago while attending a birthday party for a good friend, I was recruited one last time toward surgical pursuits. A grass skirt clad partygoer I'll call John Dole drunkenly confessed to the party's host his jealousy of the coconut bras being sported by some other men in attendance. In a move right out of Miss Manners, the host took matters into her own hands by handing me a pineapple and a knife. The procedure performed, and its stunning results, are chronicled by the accompanying photos. Eat your heart out, New England Journal of Medicine.

Elbows Thrown, Hip Check Held, Not Proud...

2006-01-24T10:37:00.000-08:00

Time flies when you're...well, mostly having fun. Finished ob-gyn last week and on to cardiothoracic surgery for this upcoming month. Sternum saws, beating hearts, and chest tubes...so far, so good.

As for the title of this posting: had a little run-in last week with a fellow med student, and it has been weighing heavily on my mind. It was not a huge event, and as far as I can tell there will be no repercussions, but it still has given me pause about this whole pursuit of a medical degree and what effect it can have on us as people.

The rotation I just finished takes students from two med schools--one student a month from mine, and four at a clip from a slightly more prestigious (but not neccessarily better one) in an adjoining state. The timing of clerkships for the two schools is about ten days off, so I had been at the place the better part of two weeks when the other group showed up.

I must preface this by saying that of the students I've met from that other school, the vast majority are very professional and easy to get along with. Student Doctor Exception, as I'll refer to her, must recently have spent a few nights curled up with the paperback version of "How to Cut Throats and Influence People." I've been in some pretty competitive circumstances, but I can't recall anything so blatant as the tactics this woman used. Think about Julie Oh's character on "Grey's Anatomy." Now multiply that by about ten.

What really chapped my ass about this person was that when her group showed up, I went out of my way to be nice to them--gave them the grand tour, the inside scoop on program politics, and some crucial notes were not provided to me when I showed up. Maybe she somehow perceived that I was at an advantage and decided she'd have to knock me off to become Alpha Dog (or bitch, as the case may be.) Which is kind of silly, considering that we go to different schools, have different professional interests, and will not, therefore, be competing for a residency spot.

All of which I tried to keep in mind while for two weeks while this person severely tried my patience. I did a more or less decent job ignoring her moronic behavior, right up to the last day of the rotation. About ten of us were walking through the Path Lab to look at some cancer slides--the setup of the place is a small room with four interconnected microscopes--we were about a step and a half from the microscopes when Ms. Congeniality not-so-subtly pushed me aside to get the seat I was headed for. At that moment, despite all my deep-breathing and oathes against agressive acts, my right elbow flew away from my body, into her ribcage, and it was all I could do not to throw her into the nearest doorframe.

Immediately, I was ashamed of this response. Still, I can't convince myself that letting her push me aside would have been the right move either. Probably some alternative route involving a quiet discussion and mediation would have been the best choice, but at that sleep deprived moment, it just didn't happen.

Nobody in the group commented on the interchange, but I'm sure it was seen. I know I didn't sleep that night, although I doubt Student Doctor Cutthroat lost any rest over it. What I do know is I don't want to be like her, and I'm glad those characteristics really are not required to be a good doctor. Now, I'll just have to convince my elbow of that...

A Room, With Materials...

2006-01-07T16:50:00.000-08:00

Ob/Gyn, week two of four. Not what I want to do, but pretty darned interesting. Some of the things I've learned, in no particular order:

1. Shoe covers exist for a reason, especially in the delivery room.

2. Every woman who delivers a baby deserves the equivelent of the Purple Heart.

3. Observeration #2 not withstanding, it's a bad sign if the mother-to-be watches "Nickelodeon" or "Divorce Court" through the delivery.

Spent three days this week shadowing a Reproductive Endocrinologist. What that specialty boils down to is assisting infertile couples in conceiving. Although heavily reliant on technology, this is as much art as science.

You can probably imagine the level of emotion involved in these interactions and the people skills needed to deal with the feelings that come into play for the patients and their partners. One definite up-side here is that the patients are a highly motivated group, a much different demographic than the "can't afford the ultrasound but can't give up the cigarettes" crowd the typical obstetrician is confronted with.

The guy I was following has a big following, evidenced in large part by the number of his patients who are doctors or nurses themselves. One of the ways he builds confidence in his practice is to recruit really top-notch staff. Another is an immaculately decorated office: expensive furniture; expensive prints on the walls; not a speck of dust in sight. Which, in part, explains an overriding and morbid curiousity I developed during the week...

At a certain point during every consult, the good doctor delves into the particulars of providing a sperm sample. Being the astute and tactful gentleman he is, all of this is couched in very subtle language, leading up to mention of a certain "Room, with Materials." Nestled into my thousand-dollar chair, I'd have to bite my lip at the mental image of a porn-corner in the walls of this fine, fine office.

No self-respecting med student could have left the practice without at least attempting to get a glimpse at the Room. The problem: being the classy facility it was, there was no sign tacked up to divulge its location. Which would neccessitate skulking around the office when the halls looked empty, opening every door, excuse at the ready in case I was discovered. (Porn room? Gosh no...I was looking for paperclips.) Not so subtle...

I never did find the Room. Not that I tried all that hard. Maybe it's better that way.

Cut Flesh to Save Flesh

2005-12-14T10:15:00.000-08:00

Third week of my surgery rotation. Digging it more than I thought I would (admittedly, expectations were low.) If I were ten years younger, I might even consider this as a specialty. Being in my mid-thirties, though, and still wanting to have some semblance of a family life, I'm probably not going to go that route. Not to mention the fact that my hands are already much shakier than they were in my twenties. Extrapolating out to the end of even the shortest surgery residency, I'd be forty two. Not gonna work.

Looked on this morning as my attending told a 74 year old lady she had breast cancer. I thought he did a really admirable job of telling her this news without either breaking her spirit or sugar coating the prognosis. I suspect that his good reputation and success in practice has as much to do with those kind of skills as it does his abilities in the operating room. Still, the woman began to shake and tear up as the conversation progressed, while her daughter reacted with disbelief and then anger. I guess it's good to see these interactions as an observer before having to be the one breaking the bad news.

As for the hospital I'm currently at, I like the residents and staff a lot, but I think there is an inordinate amount of bullshit thrust on them by the administration, which has an understandably negative impact on morale. As an example, yesterday we had to endure a ninety minute lecture by a visiting professor of ethics on the subject of "Reasons for Conflict Within Residency Programs." As I recall, the top three reasons discussed were lack of sleep, paperwork overload, and miscommunication between administration and residents. All very nice, but wouldn't it have made more sense to alot those ninety minutes to getting work done and sending folks home so they CAN sleep? Joseph Heller, if you could see us now...

Oh, the Gall

2005-11-28T17:18:00.000-08:00

First day in surgery...three gallbladder removals and a hernia repair. Looks like I've lucked out as far as resident and attending...they're intense and demanding but very willing to teach, and also not mean. The only negative of a twelve hour day was a management level nurse who refused to show me tomorrow's OR schedule on the grounds that it "would be a HPPA violation." Oh well, one miserable curr does not a day ruin.

After the initial panic over getting scrubbed and in position without contaminating everything in the room and/or making a scene, I was pleasantly surprised to find that things in the OR follow a kind of rhythm, and that once you pick up on it, time kind of flies. My involvement today was limited to holding retractors, cutting stitches, and applying staples--not very highspeed--but more than I thought they'd let me do. And pretty cool, even for a person who has not once lick of desire to become a surgeon!

I spent a lot of the day watching the nurses get the tools the surgeons called for and figuring out what those tools are for. There are about six million different kinds of clamps and scissors, all of which are named for long-dead founding fathers of surgery. So although none of the names are self-evident, all the tools have a specific place and purpose. A purpose that I better figure out pretty damned fast.

Retractors are what the people assisting the surgeon use to hold open the incision and surgical field. They are sort of a curved, stainless steel cross between a jai-lai stick and a spatula. Holding retraction is a med student's bread and butter, and can get a little tedious, being that the holder has to apply a good amount of force while standing in an awkward posture. Following closely along with what the surgeon is doing and trying to anticipate the next move makes the task a little less tedious, but it's still very possible for a person's hands to go numb and their mind to follow suit.

Another big med student job is cutting the ends of sutures after they have been placed and tied by the surgeon. This is sort of like being the guy in the orchestra who hits the kettle drum once, maybe two or three times on a good day, during a performance...you're involvement is limited, but if you lose track of time and are not ready at the right moment, it's gonna be noticed. My particular surgeon likes to do eight "throws" on every deep knot and four on the shallow ones. This requires me to count the number of times his hands cross and be ready with the scissors at the right time.

Tomorrow morning will be my first experience dealing with non-anesthetized surgical patients, which should be interesting. One poor fellow went in for a gallbladder removal and is going to find out that we think he also has cancer. I've never had to break that kind of news yet.

Katrina Relief Part Two: Moving Comments and Appeal for Help From My Colleague Nurse Michele Logan

2005-11-24T13:55:00.000-08:00

Hope everyone had a Happy Thanksgiving. This year, I am extra thankful for all the blessings in my life that I take for granted sometimes. Before you read this, I want to say thanks for taking the time to do so. This letter is LONG. But, this is an issue that is so deeply wedged into my heart right now, it hurts. I asked my husband to pass this to some of his friends, along with his weekly football pool rant. I appreciate your time.

I am hoping to enlist some of you in an effort to make the holiday season a bit brighter for those people on the Gulf Coast affected by the hurricanes.

Recently, I had the privilege of spending two separate weeks in Vidalia, Louisiana, at a volunteer clinic for evacuees of the two hurricanes that struck the Gulf Coast region. Vidalia is a poor little town on the Mississippi River. The whole place probably spans 10 miles. This little town, however, took on more than 2500 evacuees. They sheltered them in their churches, their "hotels" or their homes. They sponsor them, they do for them, and they love them. Ask why they are so invested in helping people from a region almost 200 miles away, they look at you as if you are simple, and say "There but for the grace of God..."

The photos you see above were taken by me and some of my colleagues when we traveled down to the Gulf region. They are not from a magazine; I saw this with my own eyes. It was hard to believe that we were in our own country. We said to each other that this must be what it looks like after countries are bombed. The three “D” words, destroyed, decimate, devastated, were all that came to mind as we drove through New Orleans and Mississippi.

In New Orleans, wind had torn places apart, power lines hung all over the streets, and interior furnishings line the curbs of block after block. The stench in the air is indescribable. Yet, incredibly, we found families living in their homes in the midst of this. Why? Because they are so poor, they had nowhere to go.

In Mississippi, and along the lake in Louisiana, all we saw were piles of debris that had been homes. Boats and cars were in trees. Telephone poles leaned or had been sheared off from the wind. There was no power or water in most of these places. In Waveland, Ms, there were very few structures standing. The whole town seemed to be existing in a Wal-Mart parking lot. They were hit by a 37 foot wave.

Remains of Lakefront House in Slidell, Louisiana

I want to tell you a story related to me by one of our patients. She was a 58 year old woman who has worked as a janitor in the New Orleans School District. She earns $6.52 per hour! She told me she had refused to leave her home as the hurricane approached because she feared looting. She said she had a new refrigerator in her kitchen, a TV almost 2 years old, and a 1999 vehicle. She feared losing these items to looters.

I'm thinking to myself "You stayed for your refrigerator??!” Then I realized, I can never understand her thinking, because I am lucky. In my mind, so what? I will get my homeowners insurance to cover this, and go to Sears tomorrow and get a new refrigerator. When you make 6.52/hour, you don't qualify for many credit cards. So, I asked a question and learned how many years it had taken her to save her money (eight she said) for those three items. That's why she stayed. She eventually had to leave. Her home was damaged, her belongings were looted, and she has no job to return to; no way to replace these possessions that she strove for.

Health issues will become a rising crisis. In the clinic, we saw folks who had not taken blood pressure or diabetic medicines for more than 6 weeks. They had no supplies with them. They had no medicines or money to fill the prescriptions we wrote. One of the major battles we fought with FEMA was in regards to paying the pharmacies for the meds they dispensed.

Most were showing signs of depression and post traumatic stress disorder. We heard stories from those who had been in the water for days, trying to rescue others.

We heard from a woman who had been in the Superdome, and described terror greater than anything we knew of from CNN. We heard from mothers who had given their babies urine to drink, to try to keep them from being dehydrated. Yes, that's right, URINE!

We spoke to a man who had left his aunt's body tied to a post in their attic in New Orleans so he could get back for her, and set out in the waters with his mother and sister to get to the Superdome. Their mom died on the way, and when they were picked up, they discovered a snake in her backpack. She died of a snake bite. He had no idea where his sister was, because they had been separated.

We talked to people from Mississippi who described a wall of water 16 feet high. We heard from a man who had to jump from his bedroom window, with his wife, onto a gas tank from a boat and float to safety.

We treated a woman who was getting her tetanus shot on October 27th, so she could get back to Bay St. Louis the next day, and retrieve her mother’s body. Mom had finally been found, almost two months later.

I listened to a tall Cajun man, in overalls, with a grizzly beard cry as he explained how hard it was to leave his dogs behind. He had used a stolen boat to rescue 11 different people from their rooftops and attics. He described how they had hidden from police who wanted their boat. Then he had walked 6 miles, through the muddy waters to get to the overpass and wait for a bus. He told me he might write a book about it.

THIS ALL HAPPENED IN THE UNITED STATES OF AMERICA.

Katrina devastated 23,000 acres and destroyed nearly 284,000 homes. The death toll in Louisiana alone is 1,053. That does not count Mississippi, Arkansas and Florida; all damaged by this storm system also. Schools are gone. Hospitals are gone. Fewer than 15% of the doctors in New Orleans are back at work. 71,000 businesses have been shut down by Katrina, 10,000 more by Rita. I am only giving you details about Louisiana, not the other regions.

The residents are still scattered around, waiting for assistance. They are not in their homes, or in their town, or near friends and sometimes family. Their children are in new schools. If they remain in the region, like in Mississippi, they are living in tents and eating at makeshift shelters. If they were moved to towns like Vidalia, they may be in motel rooms or if lucky, a new FEMA trailer. FEMA announced this week they will cease paying for hotel rooms as of January 7, 2006.

Meanwhile, these displaced, disenfranchised citizens have no money, no health care, and no jobs. Some have none of their essential paperwork, because it was destroyed. They left their cars back home; they left their medicine and health records at home. Many are still searching for members of their families. They must rely on the generosity of strangers to survive, while trying to maintain some semblance of dignity.

Suffice to say, the "relief" agencies like Red Cross and FEMA are largely ineffective in this effort. Bureaucracy is tying up relief. Congress allotted nearly $62.3 billion dollars to FEMA. More than $37.5 billion is still sitting in FEMA's account waiting for a purpose. Of the nearly $25 billion assigned to projects, only $6.2 billion in checks have been cashed. Because of this, Congress is considering taking back some of the money.

Meanwhile, these folks live in dirty hotel rooms, or 6 families to a home, and rely on charity for medical care, medicine and food.

I am not making up these numbers. They are documented in a Time magazine article this week.

OK, you get it. ...these folks need help. I have been told that I can’t save the whole world, so, I chose my spot. The holidays are coming, and going through them in this fashion is heartbreaking. There are 22 families that have been given FEMA trailers in Vidalia, LA. We are trying to collect money or WAL-MART gift cards for the families that have been relocated. It is so hard to imagine a holiday with no meal, or kids on Christmas morning in a ratty hotel room or a FEMA trailer, miles from home, with no presents to open, and having no choice but to rely on the generosity of strangers around you. Our goal is to present each of the 22 families with a gift card from Wal-Mart in the amount of $100.00 or more, if we can raise that.

I SAW THE TWO AMERICAS WITH MY OWN EYES. IT EXISTS, ONLY A PLANE RIDE AWAY FROM EACH OF US.

Please find a way to help these fellow citizens of our own country. The fact that they were so economically challenged and impoverished to begin with is what is making this disaster so difficult to deal with. Look at these photos I inserted. Multiply what you see by everywhere you turn.

You can send a donation, or a purchased gift card. A Wal-Mart card in any denomination will help. In the south, you can get everything - food, clothing, prescriptions - at Wal-Mart. We are dealing through the First Baptist Church in Vidalia, and the nurse who operated the clinic I worked in, Grace Woods. We are planning on sending our gift packages on December 12th. Please... join me in trying to make these folks lives just a little better. They have been through living hell, and they need to know that the rest of us care. They deserve it. They need our help and our prayers. They need us to be engaged.

Look at some of these websites for other organizations to get involved with:

www.ACORN.org - Their organizer was just awarded the RFK Human Rights award. They deal with communities in need, and are working on rebuilding the N.O. neighborhoods.

www.handsonusa.org - Grass roots group who went into the Gulf region and asked "what can we do" Doing lots of manual labor in Biloxi, MS.

www.welcomehome.org- (these are a bunch of old hippies traveling in painted up school buses. I met them in Waveland, MS, manning a relief center where folks can eat, get medical attention, and chill out)

www.catholiccharities.org - Houston/Galveston area chapter assisting those who took Katrina victims into their homes

First Baptist Church - 100 SOUTH HICKORY STREET, VIDALIA LA 71373

I know this is long. Thank you again for entertaining my thoughts. Please, pass this on to others. One person can make a difference.

Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring those ripples build a current which can sweep down the mightiest walls of oppression and resistance. Robert F. Kennedy, 1966

Michele Logan
102 Mockingbird Ct
Swedesboro, NJ 08085
Michele10j@msn.com

Next on the Rotation Schedule: Cut and Paste

2005-11-23T12:18:00.000-08:00

Now leaving the relative ease and safety of psych and radiology and moving on to surgery, the specialty where the crazy people have the knives. Also passing sort of a landmark, having completed six months of rotations with five more to go to finish third year. (Done: two months of family med, peds, ob/gyn, psych, and radiology. Yet to come: general surgery, specialty surgery, internal med, cardiology, and neurology.)

Although I have no desire (that I know of) to become a surgeon, I am more excited to embark on this rotation that I would have expected. This is probably due mostly to a really good week of "surgery prep" class put on by the head of my school's surgery department. If one were to believe the generalizations about surgeon personalities (nasty, brutish, and short-tempered, to steal a phrase from the Brits)this man is unusual in his enthusiasm and warmth in passing on the finer points of the cutting arts to med students. Hopefully there are more out there like him, particularly in the ORs of the hospital where I will be going.

On the other hand, a student in the fourth year class who has been a reliable source of information for me since I began med school said of interactions with surgical attendings, the question is not IF they will scream at you, but how often and how loud. Well, hey, it's only a month. Not that I like being screamed at, but if getting hollered at is the price of learning the stuff and getting through the month, I'm sure I'll live through it.

My Experience with Katrina Relief: Faith, Hope, and Bureaucratis Interruptus

2005-11-19T06:14:00.000-08:00

During the last two weeks of September, I had the privilege of being part of a team that opened and ran a crisis medical clinic for hurricane evacuees. The clinic was located in Concordia Parish, Louisiana, which had become temporary home to about twelve thousand displaced folks from Southern Louisiana and Mississippi.

It was one of those experiences that really jars a person's consciousness and forces a re-prioritizing of what is important in life. I could (and will, a little bit later on) go into detail about negative aspects of the experience, such as dealing with red tape from FEMA and the public health structure. Before discussing that, though, I want to emphasize that more than anything else, I was impressed with and inspired by the endurance and spirit of the people we took care of. I cannot really imagine myself keeping that of an good attitude under those circumstances. Can you?

Had dinner last Sunday night with an extended crew of docs and nurses who took over the clinic after my team left. What an incredible group of people! Over corn bread, pulled pork, and red beans and rice we shared our experiences and made tentative plans to provide more support if we can. For me personally, that meeting might end up with me following some of these folks into their residency program.

Besides eating, a major purpose of the gathering was getting together a nomination for the Florence Nightingale Award for our local host in Concordia, an exceptionally committed and brave nurse named Grace Woods. In addition to securing space for the clinic and getting people to donate the various furnishings it required, Grace put together the teams of medical volunteers from around the country, got us housed, fed, and trucked around town, and put out fires on a daily basis that would have stopped less dedicated people cold in their tracks.

It would be impossible to tell you in one blog entry all the reasons why Grace deserves this award, but I will sum it up by telling you that when she heard that she'd been nominated, her reaction was to ask why. We ended up with upwards of twenty pages of testimonials to accompany her nomination. I know there are probably a lot of deserving candidates out there, but I sure hope Grace wins.

Besides being impressed by Grace and inspired by the people we had the privilege of taking care of, experiences differed somewhat among the three teams who worked the clinic. However, two issues really came to light as commonalities. The first was the need to be creative under what could only be described as frontier conditions. When slide fixative was not available, hair spray got the job done. When lighting in the clinic was not adequate, backpacker-style headlamps were pressed into service.

(Now, for comic relief, imagine a scrub-clad med student, can of Aqua Net in each hand, getting ready to declare a medical emergency to jump a long supermarket line, stopping herself just in time to realize how that might seem to the other customers...)

The second and less comical commonality was unanimous frustration with red-tape loving bureaucrats. I am NOT talking about the boots-on-the-ground government Joes rowing around flooded streets, searching houses. This criticism is targeted at the mid and higher level wonks who not only did not do their own jobs, but seemed to relish stopping other people from doing theirs.

We came to call this phenomenon "Bureacratis Interruptus." Although it eventually was applied to all situations involving red tape, the name was originally given to one very deserving mid-level FEMA official sent from Washington to "help" in our region. Although I did not witness it personally, "B.I." became famous for telling a roomful of meeting participants he was calling his boss for an answer to a question they had posed (and posed for the third or fourth time...), then dialing his own voicemail and carrying on a pretend conversation. Unfortunately, what this gentleman did not realize was that the volume on his phone was set to such a volume that everybody within thirty feet figured out what he was doing. BUSTED!

The most heinous of the FEMA gaffs that I can attest to personally is the continued failure to honor an agreement made with local pharmacies to reimburse them for the gratis filling of prescriptions written at our clinic. In effect, this put the pharmacies in large amounts of interest-bearing debt. For WalMart and CVS, this may not have been such a huge deal. For the Mom and Pop pharmacy outfit in town that gave away $32,000 in free medicine during the seven weeks our clinic operated, the burden was huge. (As a side note, WalMart and CVS stopped honoring the deal weeks before the Mom and Pop guys did.) At any rate, this failure to pay back pharmacies was a major factor in the decision by the last team to man the clinic to cease operation and transfer care of our population to another site.

Although FEMA was the most obvious and obnoxious offender, another serious "B.I." contender was a federal and state public health structure that threw up unending obstacles re: honoring out of state licenses and issuance of badly needed vaccines. Way to encourage altruism, guys! Lower on the offender list would be the well-intentioned but out of touch leadership of the Red Cross.

(to be continued...)

Healthcare comments from "Litagatrix"

2005-11-15T13:44:00.000-08:00

Scutmonkey Chronicles is grateful for the following healthcare comments sent by "Litagatrix", who describes some interesting experiences, both good and bad, with medicine:

Worst Healthcare Experience: A while back I had to have my thyroid removed when doctors discovered possibily cancerous nodules forming in it. The good news, no cancer. The bad news, for over 8 months my thyroid levels were out of whack.

Symptoms of low thyroid hormone include fatigue, depression, memory loss, feeling cold. I had all those. I was in a very high pressure job and for 8 months I was having a terrible time functioning. I would forget what I was saying mid-sentence. I would be in the midst of a task and forget what I was doing and why. I would come home from work and either go to sleep, or break down crying.

This behavior was completely abnormal for me. When I went to my ENT who had performed the surgery, she suggested perhaps I needed a psych consult or counselling--because (without checking my thyroid hormone levels) she was sure I couldn't need a higher dose of hormones. I went to the family physician at our local clinic. After going in multiple times, he finally agreed to test my hormone levels, while all the while telling me I shouldn't be blaming my personal failings on hormone levels.
I was so angry and so frustrated.

Finally the test results came back and that doctor called me up to sheepishly admit that my TSH was 4 times the normal level---12.3 as compared to 3.1. Finally! Vindication! The moral of this story is that although there are a lot of hypochrondriacs out there, good doctors listen to their patients instead of discounting their symptoms and their assessments.

Doctors have the benefit of incredible training and experience, but a patient and his or her family are in the best position to explain "what's normal" and "what's abnormal" for that patient. Having hypothyroidism (?) for 8 months nearly wrecked my career, and could have been easily avoided had my doctors listened to my concerns and symptoms, and ordered a relatively simple test.

Best Healthcare Experience: When my son was 8 weeks old he had developed a severe case of jaudice. We took him to our family pediatrician who in turn sent us to the local hospital's pediatric clinic. There we met with an exceptional doctor.

Not only did this doctor truly love children and listen to our concerns, but when the initial tests came back indicating that my son had exceptionally high bilirubin counts, he acted immediately to follow-up with other tests to determine the problem. What made this experience so wonderful was this doctor's commitment to his patients.

When we received the initial news, he gave us his home phone number and told us to call him if we had questions later on about the tests or the eventual diagnosis. He called me at home in the evening when the follow-up test results came back, and offered to call my husband (who was travelling at the time) to explain the results to him. We never called him at home, and wouldn't have done so in any case, except in an extreme emergency. But it was so comforting to know that he cared enough to make himself that available. As a professional myself, I now give that same courtesy to my clients.

Healthcare Comments from "Grasshoppah"

2005-11-15T13:40:00.000-08:00

Submitted by my good friend Grasshoppah, an engineer with some thought-provoking insights on the practice of medicine:

1) Doctors need to ask patients more about their diet and daily routine. If they are claiming that they are tired is it because they work three jobs? If they are eating fastfood every meal; yeah their cholestrol will be sky high. Before medicating the symptom, try to figure out if it is a product of their chosen lifestyle.

2) Medications are first tried on animals then a select few humans, passed by FDA & finally released to GP. Those first few humans that they medications are tried on; how is their lifestyle documented? For instance; GP drinks caffeine. I would suspect that those first few human subjects drink caffeine. DO you think that maybe the medication works differently on those that do not drink caffeine? Women?

3) Also, have been told that once I am pregnant I will have to take injectible Fragmin every day to thin my blood (I have an anti-cardiolipid sp?; my blood coagulates quicker than others). Fragmin has been used for many years...they tell me that they have been using it on pregnant women for a few years...where are the studies saying that it is okay to use on pregnant women?

A Little Radiation is Good for the Soul

2005-10-31T09:41:00.000-08:00

FIRST of all, really like the comments so far about healthcare experiences. Hope the discussion will continue.

Done with psych, on to radiology. Interesting so far, but perhaps I'm biased as Marie Curie is one of my big heroes. Downside is we're back at school for this, which may as well be seventh grade after six months of being out in the "real world."

Maybe it's the "little leaguer taking batting practice with the Yankees" phenomenon of steep learning curves being the only way to make real progress, but at this point I'm not sure a one millimeter blip on a twelve by fourteen inch chest x-ray will ever be meaningful to me. It will be interesting to see what the improvement in skills over the next two weeks will be...

Disinfected? Disaffected? Good, Bad, Ugly?

2005-10-27T13:50:00.000-07:00

Had a good, bad, interesting, disgusting, experience with the healthcare system lately? Inviting patients, students, practitioners, etc, to leave comments here. Maybe we can generate some ideas, spark some changes, or maybe just vent, but I'll bet if you've taken the time to hit this site, you've got SOMETHING to say...

Recommend you sign your comment with a nickname (i.e. not your real name) if you choose to discuss a particular hospital, doctor, etc. or one who could be easily identified by context.

Mixed Mercies.

2005-10-25T14:05:00.000-07:00

An interesting but very draining week. On the up side, saw one very ill young man (paranoid schizophrenic, last week thought he was a biblical prophet) make a complete turnaround four days after starting on antipsychotic meds. On the down side, watched in horror as a borderline patient (a particularly frustrating pathology) pulled up her sleeves to show me the "tiger stripes" she had etched into her forearms with the end of a paperclip. Amazing what our brains will do to us, bathed in the wrong mix of neurotransmitters.

Every Rose Has Its Thorns

2005-10-19T15:06:00.000-07:00

Ah, psych...a pretty intriguing and plush rotation when compared with the others I've done so far. For human interest and humane hours, it can't be beat. The residents and attendings I've interacted with thus far are smart and decent. Refugees from other specialties come every week to check out the program and consider switching over to the psych-side.

So of course, one is tempted to consider this as a chosen specialty. And yet...

For every positive outcome I've seen take place, there are six or seven or fifty patients hanging around the day room without a seeming hope of improvement. Some get worse and not better under our care. Not even the positive changes can be wholly attributed to the profession.

Then again, are positive changes in any specialty ever wholly under control of the medical staff? Isn't there always an element of spirit, fate, luck, or whatever you prefer to call it, to healing? And don't psychiatric patients, possessing of a positive prognosis or not, deserve our best attempt at care?

As far as I can tell, to be both a good and a fulfilled psychiatrist, you would have to be not only tolerant of ambiguity but be able to thrive in a sea of it. One online test I have taken designed to match future specialty to med student personalities told me that I might be such a person (http://www.med-ed.virginia.edu/specialties/TestStructure.cfm , I would recommend this whatever specialty you think you're destined for...)

Then again, after nearly a month of this, an argument against choosing psych has emerged, and it goes like this: Why not head toward something like family med, where you interact mainly with highly functional patients, problems like hypercholesterolemia can more or less be brought under control by the numbers, and the vast majority of patients get better?

We shall see...

Scutmonkey 101

2005-10-12T15:26:00.000-07:00

What's it like to be a medical student? Interesting. Fatigue inducing. Exhilarating. Expensive....

Not sure how this experiment will work out, but hey, what harm can it do? At a minimum, it will be a place to record the highly strange and wonderful occurances of life on the wards. Maybe it will be of interest to somebody, or perhaps not. Whatever. Whether you are a fellow scutmonkey or an interested interloper, I would love to receive your feedback and comments.

I'll throw out one question here as a discussion starter, a question that I have been asking friends, family, and random strangers since I embarked on the mixed adventure of med school. That question is "What has been your best, and worst, experience with the healthcare system?" Maybe we can light a spark and solve some problems, maybe not.

Anyhow, right now it is October of 2005. I am in the middle of my third year of school, ten days into a psychiatry rotation at a well-regarded private hospital in an eastern metropolis. On the whole, I like third year a whole lot more than years one and two. That neccessary but stultifying break-in period required far too much of two things I am not very good at, which are (1) sitting still for hours at a time in a plastic seat inside a not-so-well-ventilated lecture hall, and (2) rote spitting back of information in multiple choice format.

Third year is actually more demanding in the respect that we are (somewhat) responsible for the welfare of real people, but a hell of a lot more interesting. Common sense and compassion have become at least as important, if not more so, than the third substrate of the Krebs Cycle. Thank God!

Anyhow, enough babble for today...