Wednesday, October 1, 2014

Stress

Lately I've noticed that more and more, I feel like crap. I almost never feel completely good physically. If I don't have a cold that lasts forever, then I pulled a muscle somewhere, or there's some other physical ailment bothering me. I mentioned this to my husband the other day and he said it was probably because I was stressed out.

That may be the case, but what am I supposed to do about it? Everyone says to meditate, but you know what? Meditation is boring. It seems to take tremendous discipline to do, and I don't think I have that kind of discipline.

Exercise is probably another option, but aside from not really having time for it, every time I start to launch an exercise routine, I come down with some sort of flu or sprain my ankle. Then I start to get stressed out that I can't exercise.

Honestly, I am starting to see how people become addicted to sedatives.

Tuesday, September 30, 2014

Dr. Orthochick: Consent

Me: Do we have consent for [patient]'s surgery?
Nurse: No, the family wanted to talk to Dr. Ortho. They had a lot of questions and they wanted to talk to a doctor.
Me: Well, maybe i can answer them so we can get consent tonight and we don't have to worry about it tomorrow.

***

Me: Hi, I'm Dr. Orthochick from orthopedic surgery, I'm one of the residents working with Dr. 0rtho. I heard you had some questions about the surgery?
Patient: Yes, what time is it going to be at?
Me: Tomorrow afternoon. Anything else?
Patient: No, that's it.
Me: OK, can I get your signature on a consent form for the surgery?
Patient That's fine.

4 years of undergrad, 4 years of med school, a year and a half of residency, and I'm qualified to tell people when their surgery is going to be. I really question the value of this degree on a regular basis.

Also, I always like to get consent myself so I can answer patients' questions, although I've noticed they only ask two questions:

1. What time will the surgery be at?
2. How long is it going to take?

And those are the two things i can't answer. What time it'll go at depends on when the surgeon is free and how many other things are going on in the OR at that time, as well as how many other traumas we have to do and who's the most injured. Plus, to quote Dr. Monday, "a chance to go early is a chance to go on time." Surgeons are not known for being punctual. Especially if your surgery is scheduled for after the surgeon finishes at clinic. Then you're really screwed. As for how long it takes, I don't like to tell people that because if I say it takes an hour and it takes longer, people really start to flip out. So I just say we won't know until we get in there and see. Which people seem to accept, even though if you think about it, it doesn't make that much sense. There's really not all that much we can get from looking at the bone vs. looking at an x-ray. So yes, I'm anal about getting consent myself, but in the grand scheme of things, I don't think it really helps the patient, since I can't answer the only two things they ever want to know.

Monday, September 29, 2014

Teacup pain syndrome

Patient: "Doctor, I've got pain in my left hip."

Me: "When does it hurt? When you're walking?"

P: "No, not really."

Me: "Does it hurt when you're exercising?"

P: "No..."

Me: "Does it hurt right now, while you're sitting here?"

P: "No, not right now."

Me: "Okay, so when does it hurt?"

P: "Doctor, it hurts when I do this." [Patient stands up, spreads his legs apart and lifts his left hip while simultaneous fully externally rotating it. Sort of a "I'm a little teacup" pose.]

Me: [barely concealing laughter] "Well, how often do you have to do that?"

P: "I guess not too often."

Me: "Okay, just try not to do that anymore."

Saturday, September 27, 2014

Weekly Whine: Westinghouse

When I was in high school, there was a contest called the Westinghouse science contest. It's one of the biggest science contests in the country and it's since been renamed the Intel science talent search.

Becoming a semi finalist in this contest was a pretty big deal, and becoming a finalist was an even bigger deal, and of course, winning with the hugest deal of all. I entered the contest, but didn't win and did not even make semifinalist.

I know this is going to seem like sour grapes, considering everything, but now that I know a lot about the contest, I think it is all sort of bullshit. I worked in the lab with three other students, and we were each basically randomly assigned projects. Before we started the project or even wrote one word, I could've told you which of the four of us was going to be the semi finalist, based on how interesting the projects sounded.

Don't get me wrong, there were people who came up with math projects that were entirely their own invention, and they were geniuses and definitely deserved to win. But I would say the majority of people who did well just lucked into a really good lab and got assigned an interesting project. For example, I am sure that anyone whose project involved PCR was just following what their mentor told them to do. I know from my own lab, the guy who was a semi finalist didn't do any more work than the rest of us, and basically had no creative say in the project. We all just followed what our mentors told us to do.

I guess this is the fatal flaw in having high school students do fancy science projects.

Thursday, September 25, 2014

Tuesday, September 23, 2014

Dr. Orthochick: Amputation

During my first month of internship (that would be Vascular Surgery), we had a patient come in with gas gangrene. She was totally septic and actively dying, so about the only thing we could do was amputate her leg in a guillotine amputation. We cut it off a little below the knee and didn't even bother to cover the stump because we knew we'd have to go back to revise it. You could see the ends of the bones and the muscles like some sort of weird cross sectional drawing. Anyway, we then went back and revised her to an above knee amputation. By that point she was doing a little better, but she was still in florid renal failure and I don't even remember what else. So she started getting better and one day I was rounding on her while she was in the dialysis center, she was a little more with it, and then I went to write my note.

I have no idea what happened, but she started crying and the nurse ran over there and the patient said "I want to know what happened."

The only person in the room who knew exactly what happened was yours truly, I was writing a note, I was running low on time, and really, I didn't know how to explain to a woman that we just cut off her knee. (This was long before I had to tell people they were going to die/their spouse was going to die/their spouse already died/they were never going to walk again/they had metastatic unresectable pancreatic cancer...) So the nurse asked me to talk to the patient despite the fact that I was practically hiding under the computer in an effort to be innocuous, and I went over there to see her.
Her: What happened?
Me: Well...you got really sick, you know? And the only way to get you better was to, uh, cut off your leg.
She was crying and said, "I don't want to hear this anymore."
Me: No, I want to talk about this with you. We cut off your knee. You don't have any leg past your knee. But your infection is mostly gone. You're getting a lot better. I've been talking to your husband and he's been here every day to see you and he's excited to see you get better--he told me your anniversary is next week. So you don't have a knee. But it was the only way we could get you better.

I remember I had her reach down and feel her stump and that really made her cry. Truth be told, I don't think I did a great job breaking the news, but looking back I'm not sure how I would have done it all that differently. I guess i could have eased into it a little more, although it's pretty hard to soften up "we cut off your leg."

***

Flash forward a year and a half and I still really hate having to tell people we amputated their bodyparts. I've had to do it 2 or 3 times since July of 2010 and really, it's up there with the "you will never walk again" speech for me. Anyway, yesterday I had a guy come into the ER with a huge open hand laceration. I took about three looks at it and called Dr. Pregnant.
Me: This is going to have to go to the OR
Her: What is it?
Me: An emergency. I'll call the OR and get everything started.
He had gotten his hand stuck in a woodchopper and there was a huge gash going across the palm. Through the gash, you could see the tendons were cut, as were the bones. Bone fragments were stuck in the severed tendon ends, and the whole thing was bleeding profusely. I touched the index finger and it flopped backwards. The joints of the middle finger were dislocated, so it was bent the wrong way in the middle. There was still wood in the whole thing.

We got that case booked pretty quickly, Dr. Pregnant came in from home, and we started working on him, at which point we realized all the tendons, nerves, blood vessels, and bones to the index finger were cut, which meant the finger was totally dead. This also explained why it was so cold and it didn't bleed when we cut it. So we had to amputate it, because you can't keep dead fingers on your hands due to the high risk of infection. (and really, would you want a finger that was only attached to the rest of your hand by skin?) We then did some exploration and discovered that a lot of his blood vessels were ripped in half. We repaired the tendons, fixed most of the bones, and sewed him up, with the plan being to watch him for the next 24--48 hours and see if his fingers survived. If they did, we would go back and fix the nerves, if not, choppy-choppy.

That ended kind of late at night so I wrote my orders and figured I would tell the patient the details in the morning. So I was doing my morning rounds and the nurse came up to me and said "[the patient] is really worried that his index finger is numb." I said "that's because we cut it off." She said "I didn't know that," I said "neither does he. I was about to tell him."

Me: Can I talk to you for a little bit?
Patient: OK. Why is my hand numb?
Me: That's what I wanted to talk to you about. See, when I saw you in the ER, I told you it was a really bad injury.
Him: Yeah, it was bad.
Me: Well, it was so bad, that we had to cut off your index finger because it died because it was so badly injured.
Him: Oh my G-d.
Me: So now you only have 4 fingers. But we're really worried about your middle finger and your ring finger. Because when we saw it in the operating room, a lot of blood vessels were cut. If you don't have blood vessels, the finger is going to die. So we're going to watch you closely for the next 2 days to see what happens.
Him: I could lose my hand?
Me: No, you're not going to lose your hand, but I will tell you now, I think there's a greater than 50% chance you could lose your middle and ring finger. Your pinky is fine and your thumb is fine, but those two fingers didn't look good in the operating room.

He cried. As I would too if you told me you were going to start cutting off my fingers.

I wonder if this is the sort of thing you get used to doing. The other day I was talking to an attending and he said he called his dad to talk after he had to amputate an arm and it made me feel really good to know that other people also feel weird and guilty about cutting off bodyparts. As much as I appreciate a good amputation, it just feels so unnatural. Especially when you do it and they don't even know. I mean, how do you explain 'while you were sleeping, we cut off part of your body?'

Monday, September 22, 2014

Foreign accent syndrome

Recently I made a post about things that you see in movies involving brain injury that don't really happen in real life. But I don't want to spoil all the fun, so I thought I would make a post about something cool that actually can happen in a brain injury that you wouldn't think was real, but it is. And that's foreign accent syndrome.

I recently saw a case of this, and I talked to a neurologist who told me she's actually seen many cases in her career, Although most of these involved stroke. Some cases she told me about:

1) an Italian American man who had started speaking with a Haitian lilt

2) A native Californian who started speaking with a British accent

And all of these cases, the patient had never even been to the country whose accent they had adopted. Apparently the etiology involves damage resulting in altered pitch or mispronounced syllables, causing speech patterns to be distorted in a non-specific manner. So it's just a coincidence that your speech sounds like it comes from a specific place.

As far as I'm concerned, it's a good thing that can come out of a stroke or brain injury if you are an American. As Jason Lee said, Americans totally got screwed on accents.

Saturday, September 20, 2014

Weekly Whine: Life Insurance

Recently, my husband and I purchased life insurance. It was one of the hardest things we've had to purchase, which seems sort of ridiculous. Isn't life insurance supposed to be really easy to buy? Like, aren't you supposed be fending off life-insurance agents who want nothing more than to sell you a policy?

The first person we approached to help us buy insurance was somebody recommended by my boss. He said the guy was very reliable and fair. Unfortunately, it didn't work out, for reasons that somewhat confused me. My husband was concerned about our health information being sold to a third party, so he asked the guy for some sort of written guarantee that this wouldn't be done. The guy became offended and said he didn't want to work with us anymore.

The second agent was a recommendation from a friend of mine. She got her life insurance through him, but he also handled her investments. That was sort of a red flag, but I didn't realize it at the time. The other red flag is that he worked with an insurance company named Guardian. So obviously, despite his assurances, it was less about getting us a good deal and more about getting us to buy insurance through his own company. And also to make investments with him.

Initially, I was taken in by the fact that he was charismatic and said all the right things. I don't pretend to be incredibly savvy as a consumer, and I think I was taken in by every sales trick in the book. We went through our physical exams and we were offered policies that sounded fairly high. Mine was kind of high, but my husbands policy was really high. Now, he is a man and he does have some minor medical conditions, like sleep apnea, but this was out-of-control high. People at work that I told about it said that somebody 20 years older would probably pay less than that.

I told the agent that I wanted him to look into some other companies and he sounded shocked. He said that the policies we got were pretty standard. But if I insisted, he would look at some other companies. Basically, his suggestion was that my husband should buy whole life insurance instead of term life insurance due to the fact that he has so many medical problems (he doesn't actually).

We gave the guy a grace period to look into other companyies, but it was beginning to feel like he was just putting us off. And it also felt like he was lying to us and I really didn't want to buy anything from him anymore. At the point when he explained not having called us due to a family member's death and I actually believed he had made the whole thing up, I realized I probably shouldn't be buying anything from this guy. So I went and found another agent.

We had to go through the physical exams all over again, which sucked. But not long after, the third agent came through with a policy for me, which cost about half of what the last agent had offered me.

Unfortunately, my husband wasn't getting any offers. The reason for this was that the company hadn't received one piece of his medical records. I ended up having to make about a dozen phone calls to try to track down his medical records. Obviously, it would be too easy if the medical office actually had those records. I had to go through a third-party, who kept telling me to go back and call the medical office. The whole thing ended up taking months to straighten out.

Finally, my husband was offered a policy. It cost about 1/5 of what the offer had been through Guardian.

At least now we can die in peace.

Thursday, September 18, 2014

Why a doctor?

When I ask a patient if they have any questions, sometimes they take this as a license to ask me whatever personal questions they'd like to know about me. The two favorites are how old am I and where am I from.

Yesterday, a patient came up with a new one: "What made you become a doctor?"

I haven't been asked that question in a long time. I quickly stammered my medical school interview answer. "There are so few fields where you can really help somebody…"

The patient seemed pleased with that answer. And even though I felt silly saying it, there is a grain of truth in that. I do like helping people.

But what's the other real reason?

1) my father, who is a doctor, pushed me into it

2) I wanted a career where there would be a stable, good, steady income

3) there was no other career path that I was particularly drawn to

How about you? Why did you decide to go into medicine?