Medical specialty algorithm

Should you go to med school?

How to read an EKG

7 Types of Physician Handwriting

What's in your white coat?

Stages of studying

Holiday hiatus

I will be taking a break from posting for the holidays and therefore will be rerunning some of my very favorite cartoons in my absence. I will return as scheduled with new posts in 2015. 

Happy Holidays!

Dr. Orthochick: Friend me!

I got a friend request on facebook yesterday from someone I didn't recognize, I looked at the pictures and it turns out he was a guy I saw in foot&ankle clinic last week for his foot pain.

I politely declined that request.

Is it just me, or is that a little weird? I mean, I wasn't examining his bunions because I wanted to sleep with him. My sole interaction (no pun intended) with this guy was limited to talking about his foot problems. I'm not even sure how he remembered my name long enough to look me up on facebook.

This is probably a sign that I should either get off facebook or change my name on it, both of which would probably be fine since I rarely go on it to begin with. Because even though this is the first patient to try and friend me, I really don't want to be friends with patients at all. I don't really post anything on facebook and most of my friends don't tag me in posts, I don't have any incriminating photos, and there's actually not all that much personal information up there, but I still do not want my patients to see it. I don't want to blur the patient-doctor relationship here. And, truth be told, if they're not sitting in front of me, I don't really care what they're up to.

Put frankly, I do not want to be friends with my patients.

I don't know if I gave the guy the wrong idea or something, I thought I was pretty professional and it's not like I asked him to take off his shirt or something so as far as physical exam goes, foot&ankle is pretty low on the sexy totem pole, but maybe I said something wrong?

Me: Hey, you remember that younger guy we saw last week with the bunions? He sent me a friend request on facebook!
Dr. Critical: You're welcome. I guess that's an unintentional perk of the foot&ankle rotation--you get to hook up with the patients.

Evaluations

Actual line from an email I got during residency from my 67 year old department head to my entire residency program:

"Also worth spending a little time on milestone expectations so you know what you are being ejaculated on."

The number of texts and emails that followed that said some variation of 'my face' was starting to get a little extreme. Also, even though I felt like my program was constantly crapping on me, I never really felt like i was being ejaculated on.

I guess someone pointed it out to the boss because a few hours later he sent the following email:

"It has been pointed out that I used the incorrect use of Milestones in my last email to the group. We really use them to evaluate each resident."

(italics his, not mine)

I don't even understand how you could make that typo. "v" and "j" are not that close to each other on the keyboard. I guess we know what the boss does in his free time in his office.

He never managed to live that down and luckily retired shortly after.

Weekly Whine: Presents

I don't really believe in getting presents, mostly because I think that it's impossible to get somebody a present without making somebody else feel slighted.  Half the time, people don't even want what you got them.

Case in point, I was recently pressured to go in on a Christmas present for a coworker. Except if I get a present for this person, there are at least eight other people who would feel slighted if I didn't get them a present. So now I have to figure out what to do for eight other people. And there are probably a bunch of other people that I'm not even thinking of right now who will also be insulted.  This is really stressing me out, considering I usually just bring some treats for everyone to share.

Not to mention like 10 teachers and daycare workers that I have to get stuff for...

I think people should only give presents to children, and everything else should be communal baked goods.

Sexual abuse is OK?

I had a patient in residency who had a brain injury and we couldn't discharge him to his parents' house because he sexually abused his sister when she was nine (she's 14 now, and the patient had been living with his grandparents so he wasn't near her). I was mentioning this to the new attending and he was like, "So what? He sexually abused her a long time ago. He should still be able to live there."

Uh, okay... "I was told that if he goes back home, we have to report it to child protective services."

"That's not true," the attending insisted. "He hasn't expressed any intent to hurt her so we don't have to report it. The sexual abuse was a long time ago."

"Yeah, but he's already attacked two women here!"

"But his sister won't be involved in his care," the attending said. "They'll be living in the same house, but she can avoid him. And she can leave the house if she wants."

I didn't even know what to say to that. I mean, how would he like a serial killer living in his house, provided the murderer hasn't specifically stated he's going to kill him and he doesn't have to go near him? I was totally baffled by the fact that he thinks there's nothing wrong with making a 14 year old girl live in a house with a guy that abused her. And "she can leave the house if she wants"? WTF? She's FOURTEEN, not forty. Where was she supposed go?

Dr. Orthochick: Pinky

I got paged in around 23:00 the other night to reduce a kid's pinky finger. I would have been less annoyed, except it was the second time in a week that I've gotten paged in around 23:00 to reduce a kid's pinky finger. It's times like this I really wish the ER knew how to do stuff like reduce fingers. (they tried once earlier this year and then I got paged to redo it when they messed it up. So I guess they're scared of trying and honestly, redoing their crappy work was harder than if I had done it myself in the first place so I probably shouldn't complain, but seriously guys, it's a freaking pinky.)

Me: So when did this happen?
Mother: Around 19:00. So we went to (outside hospital) and they told us to come right here.
Me: Uhhh...
Mother: Well, first we went home and [patient] took a shower and then she had dinner and then we came over here.

One could make the argument that if you feel like showering and eating dinner, you probably don't have an emergency going on, you could also make the argument that doing a reduction sometimes requires sedation and if you've just eaten it makes it that much harder to do that. But I was telling this story to my sister and she brought up the time that she fell off her bike and needed stitches in her chin and mom convinced her to shower first under the pretense that she would feel better. She claimed that she did not, in fact, feel better, but this is the same sister who continued ice skating after she broke her elbow and continued skiing after she separated her shoulder. And the same mother who told me I was too old to have an earache (I was 13 or so), at which point my eardrums ruptured and leaked pus into my hair for the next week and I wound up on 2 courses of antibiotics.

Anyway, reducing kids' fingers is annoying. I'm a big fan of sedation for pediatric reductions. One of my coresidents never does it and things seem to go fine for him, but i'm of the opinion that you can only get away with that if you're convinced you can get it on the first try. And I'm not. So usually I sedate kids because it's a lot easier for me to do a reduction if they're relaxed, I can do it as many times as I need to to get it perfect, and I think the parents probably prefer not hearing screaming followed by the crack of a bone. (and sometimes it really does make a loud crack.) but if it's just a finger, it's kind of overkill to sedate the kid and the risks outweigh the benefits, so the ER won't do it for you. But you don't really have great options. I could do a hematoma block, but that involves sticking a needle in the sore area and injecting numbing medication, which burns. I could do a wrist block, but that's three needle sticks and burning. I could just do nothing, but then parents get mad. If it was my finger, I'd probably go for nothing since that numbing medication stuff seems to burn like hell and it's over quick anyway, (and I am sure my parents would be fine with that since over the course of my childhood I remember getting tylenol once and it was because I had a fever of 104 so really, mom and dad were not quick with the analgesics here) but not everyone's parents are so OK with hearing their kid yell.

So I gave the kid (and her mother) the option of hematoma block or nothing, they picked the hematoma block, and the kid screamed like hell while I did it and for a good few minutes after. This was after the 20 minutes of crying leading up to the hematoma block once i explained what it was. So once we did the stupid hematoma block we actually did the reduction (seriously, I pulled on the finger and got it straight. I would say this took under 10 seconds at a conservative estimate. We could have done this a couple hundred times in the time it took the kid to calm down from the stupid hematoma block)

::sigh::

At least the kid was super cute. She was actually the second super-cute girl under age 10 with a pinky fracture who I've seen in the past week, so either kids are getting cuter these days, pinky fractures only happen to cute kids, or I'm starting to get mushy in my old age.

Code Blue in the Rehab Unit

I still remember my first CODE BLUE IN THE REHAB UNIT.

My attending and I were seeing the patient in room 35, who was named Jim (not his real name). Jim was a little bit out of it and his rehab was actually stopped because he was making insufficient progress. But my attending liked him so we'd still come to his room every day (technically, only the resident had to see patients who are no longer being rehabbed).

We attempted to talk to him a little bit and made sure that his nurse call button was in easy reach of his one arm that moved. He gave us a big smile before we left the room. Little did we know...

About five minutes later, we were in the next room over, seeing our next patient. Suddenly, we heard the overhead alarm that still makes my skin crawl: "Code Blue in...."

We waited.

".... Code Blue in Two Rehab, Room 35."

Just hearing that it was on my floor was horrifying enough, but then it hit me that Room 35 was Jim's room. I was terrified for a good five seconds until I realized, "Hey wait, we were JUST in there and he was fine. How could he suddenly be coding?" That doesn't usually happen to healthy (but brain damaged) young men.

We ran back to his room and his bed was surrounded by several nurses. And he was still lying in bed, smiling.

"False alarm," one of the nurses said. "Somehow he managed to hit the Code Button."

So apparently, Jim called the code himself. I was very surprised to discover that there's a button right by the bed that's so easy to access that even a bed bound patient can hit it accidentally.

Weekly Whine: Checkout candy

I was recently shopping at a chain store with my kids. We had gathered a few purchases, which is no small feat when one of your children has the attention span of a cocker spaniel. We got on the rather long checkout line, and were immediately faced with about 20 feet of nonstop candy.

I get why stores do that. I'm sure they get a lot of people making purchases they otherwise wouldn't because they see an item while they're waiting to buy the items they already decided to purchase. I've done it myself.

But if you are a parent who does not want your child to get candy during every outing to a store, these checkout lines are torture. It is basically me saying over and over, "no, you can't have that candy either."

Reason number a million why I prefer to shop alone.

Gifts

We've had the same cleaning guy for the last three years. He's done a pretty good job with our apartment. He comes every other week and we pay him $80 per session.

I can't remember what I gave him for Christmas last year. I think I just added $20 to the check for that week. And I think he gave us a card.

Anyway, today we came home to find this array from him as a gift:



And now … I have no freaking idea what to get him. What do I do?

my time is important, damn it

When I was a resident, there was one night when I was on home call and hanging around the hospital, making sure there was nothing to do before I left. A resident on another service said that he had to leave to catch a plane at 4, so he asked if I could stick around till 5 so that if the med student needed any orders signed or whatever, I could cover for him. I said sure, because you can't really say no to a request like that.

Anyway, around 4:15, I came back to the floor and the resident was still there. I said, "Don't you have a plane to catch?"

He said, "Yeah! I'm going to have to run for it!"

"Do you need any help?" I asked him. "I don't want you to miss your plane."

"No, there's nothing I need, really," he said. "Why don't you ask the med student if she needs help? She's busier than I am."

For some reason, that got me really angry. I'm willing to sign orders or offer wisdom to his med student, but there was no way in hell I was doing her scut work so she could leave earlier. I was like wtf?! "I'll help YOU so you can make your plane," I said, "but if you don't need help, I'm going downstairs to do my own work."

And I stormed off (sort of).

Dr. Orthochick: Listen to your attending

Last day in clinic with Dr. Douche!

The nurses said if they had known, they would have brought in cake, which makes me feel good.

Anyway, Dr. Douche was in his usual mood, which means he does this thing where he seriously does not listen to anything. It's like once he decides what he's going to say, he sticks with it until I give up.

We had a lady come in with a chief complaint of knee and shoulder pain. If you have need a knee and hip replacement then you usually get the hip done first and then the knee because it's easier to rehab a knee after a hip, so I was wondering if there was an order for knee and shoulder.

Me: So, hypothetically, if this patient needs a knee and shoulder replacement, is there an order we do them in?
Dr. Douche: You haven't even seen the patient yet. You can't jump to that conclusion that she needs a joint replacement. First you need to ask about nonoperative management and what she's already tried.
Me: I know...OK, let's pretend you're not you, I'm not me, the patient's not the patient, and you and I are two other people talking about a third patient who does need a knee and shoulder replacement. Is there any special order they should be done in?
Dr. Douche: But we would never just jump to doing a replacement. We would start with physical therapy and long acting anti-inflammatories. We might then ask about injections--
Me: Ok...let's say I'm doing a practice question. The practice question tells me that a patient is having a knee and shoulder replacement. I cannot argue with this practice question so I am forced to do a knee and shoulder replacement on this patient in this practice question. So the question is asking me which procedure should be performed first?
Dr. Douche: You really need to see the patient first before you decide what procedures she's going to have done. We treat people, not xrays. Don't be so quick to jump to surgery, especially replacement surgery.

At that point I gave up and walked over to the next pod and asked Dr. Grandpa, who said it didn't really matter but to wait three months either way.

Sheesh.

Coke

I had to call a pulmonary consult once on a patient that I was covering just for the day and therefore barely knew. The consult was for possible obstructive sleep apnea... apparently, the guy drinks TWO CASES of Coca Cola every day to stay awake. Then he had a stroke.

So pulmonary came and evaluated him after an overnight pulse ox and an ABG. Since I was an intern at this hospital, I know all the residents on the consult services so I routinely get made fun of for calling consults. The pulmonary resident happened to be my resident from the ICU.

"So your patient does not have sleep apnea," she said. "Why did you call this consult anyway?"

"Well, it's not my patient, I'm just covering for the day," I quickly explained. "But I think they were concerned that he drinks two cases of Coke every day."

"Yeah, I asked him about that," she said. "He told me he just likes the taste of Coke."

Censorship

One thing that I have never done on this blog is censor comments.  For one thing, it's a pain in the booty (and mine is so painfully small to begin with). And for another thing, I think people all have the right to voice their opinion. The only comments I have deleted are the ones that are pure spam, and also ones by this one guy who kept posting really racist things.

As a result, I have several old posts, such as my one about dermatology, where the last 10 or 15 comments are all just people cursing me out. I actually have to approve all those old comments, which means I am actually saying "approve" to people telling me I'm a jerk.  It doesn't really bother me all that much though.  I think anybody who is getting so worked up and making a long reply to a post that is like three years old probably has some issues.

Anyway, my post yesterday did rile up a few feathers. In all honesty, when I do make a post that is controversial, I do it to spark interesting conversation. (I hope nobody thinks I am lying awake at night, upset about a booty song.) I've had some really interesting conversations on here… I doubt any opinions were changed, but I think both sides probably learned something, and at the very least, it was entertaining.  In any case, I don't make these posts to spark people calling me names or insulting me just because I disagree with them.  Yet unlike some smarter bloggers, like Dr. grumpy, I allow them to make insulting comments when I could just as easily delete them.  Eventually, the comments became more insulting and trolling than productive, especially from one anonymous commenter.

At some point yesterday, somebody made a very nice comment defending me. Subsequently, a second comment was made belittling that person. It was a mean and unproductive comment, and I hated the idea that somebody might feel hurt as a result of my blog, so I deleted the comment.

And then I wondered, why don't I pay myself the same courtesy?

Weekly Whine: Skinny Shaming

My husband will probably make fun of me when he reads this, but every time I hear the song "all about that base", I get a little bit teary-eyed. Because my older daughter, while not fat, is built like her dad and definitely not a "stick figure Barbie doll", and I like the idea of any song that potentially would make her feel good about herself. Not that she feels bad about herself or anything, but who knows, maybe in the future.

That said, I am skinny and I have always been skinny. But I am about as far away from being a Barbie doll as you could possibly imagine. I don't diet or do anything to watch my weight, but I am the sort of person who feels incredibly ill if I eat more than a small portion, and when I am stressed out, I end up not being able to eat it all. My father always told me that I have inherited the "McFizz stomach". I don't really feel lucky about that, but I guess it's good for my health to not be overweight, at least.

Occasionally, people make comments to me about how they think I am "lucky" to be skinny. But in general, people I know in real life don't comment much, either because they realize it's inappropriate, or because it's incredibly obvious that I am not at all obsessed with looks. If I were, I'd probably at least buy some make up and wear pants that weren't two sizes too big.

However, there was a period when I mentioned a few times on this blog that I am skinny, and there were a couple of very vocal people who got really really mad at me. I think there was one post where I said that my weight made me feel cold more easily, and somebody told me they were so angry at me for mentioning my weight that they were going to stop reading my blog. WTF?

Someone else, who claimed to be a physician, told me that just saying that I was skinny would give readers a negative body image. Because if I say I am skinny, then I am necessarily bragging about being skinny.

This completely shocked me. Even though I realize that women obsess about their weight, I was surprised that just mentioning it in an offhand way would make people so angry. In my opinion, weight is not what makes you attractive unless you are at an extreme. It's just a matter of preference. Frankly, I think I'd probably be more attractive if I gained 10 pounds. Or had silky blonde hair like Megan Traynor.

So while I like the message in Megan Traynors song, I also sort of take offense to the generalization. Just because you're skinny, that doesn't mean you are a silicon Barbie doll model bitch. You might just be a nice geeky girl with a weak stomach.

Name that injury

I know I haven't done many drawings lately, which may be why my artistic skills have been starting to deteriorate. Any guesses what this drawing I did for a patient yesterday is supposed to represent. Bonus points if you can guess the actual pathology:

Dr. Orthochick: Own it

Resident 1: Dude, you said "osteofart" instead of "osteophyte" in conference this morning.
Resident 2: Really? I get so nervous when I'm up there that I don't know what I'm saying.
Me: Oh come on, you gotta own it now. Like how I own "spontaneous vaginal deformity" and PD owns "interanal condyle" and Jared owns "depth of penetration"--
Resident 3: And I own "it eats out the PCL"
Resident 4: And i own "you whack off the condyle."

To quote Douglas Adams, "I may not have gone where I intended to go, but I think I ended up where I needed to be."

Micrographia

I saw this note in the chart recently and I swear to God, this is the smallest handwriting I have ever seen in my life:



It literally takes up 1/5 of the line!

Weekly Whine: Spam

Lately I have had a problem with emails being inappropriately labeled as spam.

I sent an email to my boss's assistant about the call schedule. Despite the fact that I have exchanged hundreds of emails with her over the years, the email went to her spam folder. Why?

And then more recently, an email I sent to my husband went to his spam folder. It goes without saying that I have sent him more than a few emails over the years, and I wasn't trying to sell him some illegal Viagra. (Or was I?)

On my end, all the emails for my daycare suddenly started going to the spam folder after having previously having been delivered to the correct place.

Best of all, an email from my mother somehow went into my spam folder. Granted, sometimes she sends me an excessive number of emails, but I'm not sure why Gmail suddenly decided that particular email was spam.

Gmail, what's up with your spam filter?

pee pee soaked heckhole

I was just thinking about the squallor I used to live in when I was a kid. My parents were divorced and my mom always felt like she didn't have any money, so she spent money very sparingly. I always joke about it, because it's not like we were poor and starving or anything, but it was just sort of funny that our apartment was always such a mess.

Like for example, we had the same ratty couch from before I was born up until I was about 14 years old. I don't know what the average lifespan of a couch is, but I know for a fact that I peed on this couch as a baby, plus the backrest was so worn down that the springs were protruding a little bit through the fabric.

Or the chair situation. We had about three chairs in our whole apartment, which might not have been so bad if two of those chairs weren't broken. They had this mesh that was supposed to serve as the seat, but they were so old that the mesh had worn out and there were just holes where the seats should have been. This might have been a good time to buy some new chairs for $10 each or whatever, but instead my mom just put a cushion over the hole and acted like it was fixed.

We had two bookcases that came directly from the garbage room.

Our TV stand was held together with duck tape.

All of the handles had fallen off the dresser with my clothes in it. I kept one of the broken handles on top of the dresser and I'd have to latch it into the holes where the handle had been in order to get my clothes out in the morning.

Our refrigerator was set weird so that it needed to be defrosted like every week. If we didn't defrost it, large icicles would start to form in the freezer.

I think the most amusing thing was the paint situation. Because we hadn't had the place painted in a long time and our last paint job was shitty, there were large areas on the ceiling and wall where the paint was chipping away. Sometimes I'd stare at the ceiling and find shapes in the chipped-away paint (like with clouds). Sometimes a piece of paint would fall on me from the ceiling. Finally, my mom realized this was getting out of hand and she got someone to plaster over the holes in the ceiling. But for some reason I don't understand, the person who plastered the ceiling used pink plaster. So now our ceiling and walls were covered with large pink spots. And it was like that for YEARS.

These same principles applied to the food I ate and the clothes I wore. This is why I have absolutely no concepts about name brands and no appreciate for nice, expensive things. And even though most of my current furniture is from Target, you can see what a huge improvement it is over the way I used to live.

Pee-wee

I was always a huge fan of the Cosby Show when I was a kid. It was a wholesome enough show that I was allowed to watch it, but it was actually really funny. It's sort of sad that reruns can't be shown because of… Well, you know.

I don't know how to feel about television shows being pulled off the air because we find out that the guy involved in it was actually a bad guy. I mean, if it's a good show, why shouldn't people be allowed to watch it? I suppose it also depends how bad a guy we're talking about.

My husband and I were recently talking about what happened to the actor who played Pee-wee Herman. For those of you who are painfully young and don't remember it, he was caught in a porn theater doing the kind of private thing that people sometimes do when watching porn movies. And because of that, his very clever TV show Pee-wee's Playhouse was pulled off the air.

I always thought that was sort of unfair. Yet at the same time, the actor did a pretty dumb thing. He took a chance, he got caught, and he paid the price.

My husband argues that he was probably desperate, because what woman would want to sleep with Pee-wee Herman? Frankly, I think there are probably plenty of women out there who would've happily slept with a rich celebrity, even if that celebrity was the guy who played Pee-wee Herman.

Dr. Orthochick: Stupid is as stupid does

Scene: Outpatient trauma clinic, me seeing patient who had knee surgery, has history of brain issue

Patient who has had 9 brain surgeries for congenital defect: Is it ok if I ride my bicycle now?

Me: You can ride a stationary bicycle but I want you to wait another few weeks before riding an outdoor bike because i don't want you to fall and put all your weight on your knee

Patient who has had 9 brain surgeries for congenital defect: I can't wait to get back on my bicycle

Me: You always wear a helmet when you ride your bicycle, right?

Patient who has had 9 brain surgeries for congenital defect: No...why?

::sigh::

Fun with Pharmacy

I haven't done "fun with pharmacy" in a while, but this is one I had to do. The order was:

Zoloft 50 mg PO qAM

Guess what time the pharmacy scheduled the medication for.

Weekly Whine: McDonald's Shaming

I am seriously sick of all the shaming that goes on around eating at McDonald's. If you don't like McDonald's and don't think they taste good, then don't eat there. But don't act like you're better than everyone else because you don't eat there or other fast food restaurants.

Someone recently made a comment on this blog that they could tell I was stressed out because I take my kids to McDonald's a lot. First of all, I don't know how a complete stranger who mostly just reads blog entries that I largely wrote before I even had kids knows how often i take my children to a particular restaurant. I probably take them there once or twice a week on average. I try to limit the number of times I take them there, not because I think they are so unhealthy, but because it's a pain in the neck to wait for the drive through and it's more expensive than making something at home. Plus then when we go to McDonald's, it's a special treat that everyone gets excited about.

Is McDonald unhealthy for children? Seriously, I don't think so. Maybe McDonald's is more healthy than some gourmet cook making special organic meals for her child every day or something. But I am willing to bet that the average woman does not give her children food that is healthier than McDonald's.

Most children love the following foods: chicken nuggets, fish sticks, pizza, etc. my kids demand chicken nuggets almost daily. I looked up the nutritional value of the "healthy" frozen chicken nuggets that I buy at the grocery store. And guess what? They have the exact same number of calories and fat as the nuggets at McDonald's. So if I get them a side of apple slices and a yogurt with the nuggets, am I really subjecting my children to something so horrible? And I think the little burger they get there is probably healthier than most red meat dishes I might make for the kids.

Probably the main reason I limit McDonald's is because the stuff that I get there is much worse than the stuff that I make for myself at home. And the temptation to get myself something is too strong if I do the drive-by.

I just think there's too much McDonald's judging going on when it comes to children. In small children, I don't think McDonald's is contributing to obesity. At least not based on the caloric and fat content of their food for kids.

Yummy lunch

Some patient on our unit had an epic bowel movement yesterday. It was one of those poops where the smell permeated the entire hallway and traveled down several adjacent hallways.

The smell even went into the back room where I usually do my charting. I heated up my lunch, with the intention of closing the door to the room and opening up a window, so that I could eat without the smell of feces in my face. Before I could do that, somebody in the room with me crinkled up their nose and said to me, "Your lunch smells awful!"

I don't know, maybe I sometimes bring weird stuff for lunch. But I'm pretty sure I've never brought feces.

Contribute!

A while ago, I informed the readers of this blog that I was building an anthology of humorous medical stories of 1000 words or more. Some of you were kind enough to have contributed stories. Well, it turns out we have enough to go ahead with the anthology, thanks especially to the generous contributions of Dr. Grumpy. Here is the cover:



I am still collecting story submissions, so if you have anything appropriate, email it to me at Fizzziatrist@gmail.com. Remember, all profits in the book will be donated to Red Cross.

Dr. Orthochick: Neverending

Circulating nurse: Schools are closed again tomorrow [because of snow]
Me: Wow, I really do not miss being in school
Dr. Orthoking Jr: Why's that?
Me: First off, I don't have to do homework.
Dr. Orthoking Jr: Yeah Orthochick, you don't have homework.
Me: Well--
Dr. Orthoking Jr: What did you do last night?
Me: I did some reading on proximal hamstring injuries, then I wrote out my operative plan for this case and the next case, then I reviewed my article for journal club and worked on my presentation for Tuesday on minimally invasive sacroiliac joint fusion.

Damn.

It never ends around here.

Scribble

I was just doing a CME activity and the lecturer had the most unintentionally hilarious slides that I had ever seen. He had clearly drawn on some of the slides, but it all just looked like freehand scribbles. Basically, it look like something my preschooler would have done, except maybe not quite as good.

Here is a sample of a slide, just so you don't think I am exaggerating:



What do those scribbles signify, exactly?

Weekly Whine: Charity

A few days ago, I was at Barnes & Noble. I don't go to bookstores much anymore, but my mother was visiting and she wanted to buy some books for the kids, so we went.

We bought a few books, and while my mother was paying, the cashier mentioned a book drive for the poor that Barnes & Noble is doing. "Oh, that's great," I said. "So I can bring in books to donate?"

Apparently not. Apparently, you actually have to buy the book from Barnes & Noble, then the book is passed on to an underprivileged child.

I have seen supermarkets do similar things. They have a bunch of items that you can buy from them, then the items are donated to charity. Except I don't understand how this is not the store exploiting poor people to make money. Because I would've been buying the Barnes & Noble book at full price. Then they just pass the book on to charity. I could just as easily donate an old book to charity myself.

What were you doing when your pager went off?

Dr. Orthochick: Respect

On Friday I was walking from Point A to a rather remote Point B and I ran into one of the peds ICU docs so we walked together. (side note: I have no idea how I know the peds ICU docs because I try to stay out of that place, but for whatever reason, I've always been the type of person who knows everyone. This happened to me in med school too)

Me: Hey, is everything OK? You seem sort of...bummed.
PICU Doc: I pronounced a kiddo this morning.
Me: Oh wow. I'm sorry.
PICU Doc: His father is probably going to go to jail.

I'll spare you the details, but it was probably one of the most sickening child abuse cases I've ever heard. (And if you're in ortho, you see child abuse. And domestic violence. And elder abuse. I don't talk about it much, but I see a fair amount of it.) Not to get too graphic, but the six month old baby had multiple skull fractures and had been shaken so hard that the gray matter of the brain couldn't be differentiated from the white matter of the brain. And that was just the injuries he had to his head.*** I wound up talking down the PICU doc for a while which was a little strange since I don't really know him, but he kind of seemed like he wanted to talk.

I've also been to some really sad places lately. The other day I was doing something in the ER and one of the general trauma docs (Dr. MarineBerg) asked if I could help him for a little while because he didn't have a resident and a Tier 1 trauma was coming in. So I followed him into Trauma Room B, gowned and gloved up...and the medics brought in a dead 13 year old. Gunshot wound to the chest. Dr. MarineBerg pronounced, I left the room.

The reason I bring all this up is because I was involved in a (different) upsetting case the other week where a 20 year old guy tried to kill himself by jumping out of a building. He broke his neck, his back, both legs, both feet, one arm, and lacerated his liver and his lung. One of his ankle fractures was open so we had to go to the OR to wash it out and do what's known as "damage control orthopaedics." (DCO for short) He was hemodynamically stable, intubated, and appropriately packaged by about 22:00 so we headed up to the OR then.

I really try to not get holier than thou, but I was disgusted by the behavior of most of the OR staff. The anesthesiologist said repeatedly he wished the kid had succeeded in killing himself so we wouldn't have to operate on him now, the circulating nurse said it pissed him off that our tax dollars would likely go toward the guy's medical bills, the scrub nurse said we should just finish the job and kill him in the OR, and my attending said he couldn't understand why we were bothering to save him since he was a suicide.

I'm sorry, I'm better than that. I was raised better than to make comments about how people should kill themselves and I"m not even going to make a comment about finishing the job as a joke. That's disgusting. I know it's late at night, but that's the sacrifice you make when you go into medicine. Sometimes problems don't happen between 9 and 5. Yes, it's inconvenient, but here's someone who really, really, really needs help. Let's do this. No, it's not what i was planning on doing with my Saturday night, but it's my job and I will do it to the best of my abilities. So I wanted to tell everyone to please refrain from making comments like that, but I didn't want to come off as holier than thou. So I didn't, but I wish I had.

I am very sensitive and I worry that since this stuff upsets me to the level it does, maybe I'm not cut out for trauma. But if the peds intensive care doc can still get upset when kids die and be a damn good doctor, then it's OK for me to get upset when people get hurt.

And quite frankly, I wouldn't want it any other way.

***If it is any consolation to anyone, all of his organs were harvested. Heart, lungs, kidneys, intestines, pancreas...everything. I think there were three transplant teams working at the time.

Fist Bump

When I started my residency, I was one of only four girls in the entire program. The hospital where I was rotating most of my first year had only male residents.

There were two male residents Nick and Rick in the program who I often ate lunch with and they were constantly fist bumping each other. I honestly can't give you an example of a fist bumping situation. It probably involved mentioning some girls booty.

I started to become intensely jealous of the fist bumping. As a woman, I felt really excluded from it. I used to talk to my husband about it, and whine about the fact that I never got a fist bump. granted, there were other guys who ate lunch with us who didn't get fist bumped either. Mostly, Rick and Nick would just fist bump each other.

Anyway, one day I said something (can't remember what, possibly involving some girls booty) and to my delight, Rick held out his fist to me. I happily bumped it. I was so proud.

Fast forward to nearly a decade later. I did something at work recently that my boss really liked. Instead of complimenting me, he held out his fist and I bumped it. I was only slightly more happy than when I get a raise.

I don't know what it is about having my fist bumped. I just really like it.

Weekly Whine: Tailgating

Last night, I was driving home on this twisty dark road. The road was so twisty, there is actually a sign on it that said "this road has dangerous turns". In addition to that, it was raining. Great driving weather.

When I turned out of the daycare onto this road, there was an SUV pulling out of the daycare behind me. Despite how dark, twisting, and rainy it was, this car stayed really close to me. It was so close, that its headlights were completely of obscuring my rearview mirror and even obscuring my windshield slightly. I really wanted the car to somehow pass me, but it seemed to be following me at every turn. Finally, when we got to a light, it quickly skidded ahead of me and went through a red light in order to pass me.

I really don't understand tailgating. I can't say I've never done it because somehow it's hard not to when do you want to get someplace fast and the car ahead of you is too slow, but it really just doesn't make any sense. This car being right behind me and blinding me was making me go slower, not faster. I don't think I've ever been tailgated by a car and it's made me go faster. In fact, I usually slow down because I figure if they slam into me, at least we'll all be going slower. I really doubt anyone speeds up when they're being tailgated.

In the case of that other car, they were doing something incredibly dangerous with their children in the car. They were tailgating on a slippery twisty road and then went through a red light. Is there anywhere you really need to get to that quickly to make it worth risking your life?

The most frequent tailgating I get is on this road near my house. I always slow down there because about 25% of the time, there is a cop car lying in wait. I'm holding my breath for the moment that the car behind me gets pulled over for tailgating me.

Books vs. Movies

I love to read. I feel like there is nothing like being midway through a really great book. My husband, on the other hand, hates to read. I don't think I've ever seen him pick up a book in the entire time I've known him.

It doesn't bother me that we don't have that in common. To be honest, even if he loved to read, he probably wouldn't be into the same kinds of books as me. My taste in movies is fairly gender-neutral, but my taste in books is very girly.

Anyway, his assertion is that people make too big a deal out of reading, like it's some higher activity. But is it really any better to read a book than it is to watch a movie? Is there a greater cultural value in reading the book gone with the wind than there is in watching the movie, both of which are considered classics? or to pick something with less literary value, the Harry Potter books versus the Harry Potter movies?

Truthfully, even though I like to read a lot, I sort of agree with him. I don't read because of any sort of cultural value. I read because I like it. I'm not sure if it's any more highbrow then watching a movie. It's just more portable and often more fun for me.

El Flu

Where I work, the flu shot is mandatory.

It doesn't mean we get fired if we don't get it or that they hold us down while jabbing at our left arm like my dad did to me when I was 16 and didn't want a flu shot. What it does mean is that if you don't get a flu shot, then during the entire flu season, you are required to wear a mask in patient care areas.

In addition to the mask, you also have to wear a badge that explains why you aren't wearing the mask. The badge says "I'm wearing a mask because I care about your health." That doesn't sound so bad, except underneath that statement is a picture of the cartoon pig wearing a mask.

Personally, I am in favor of mandatory flu shots for everybody who is capable of getting it. I have heard a lot of the reasons people don't get flu shots and I think most of those reasons are dumb, in all honesty. Most of the reasons are something along the lines of, "I never got a flu shot and I have never gotten the flu before so why should I get a flu shot?" Or, "I got the flu shot once and got sick right after, so I will never get a flu shot again."

That said, if someone has a really good reason for not getting a flu shot, like a history of Guillain-Barre, then I'm not sure it's fair to restrict them like that. I mean, wearing a mask for four months straight really sucks.

Dr. Orthochick: Feelings

Morning Rounds, me seeing 60 y/o lady after her elective spine surgery

Me: How are you?
Patient: Terrible! starts crying
Me: What's wrong?
Patient: My boyfriend broke up with me! He said he couldn't handle me being in the hospital! We've been dating since February and everything was going so well!
Me: I'm very sorry to hear that...
Patient: Can you give me an anti-depressant?

Feelings are overrated.

Code Dentures

I got possibly one of the most annoying pages ever yesterday. It was a nurse calling to inform me that an elderly female patient had stolen her elderly female roommates dentures.

And where was this lady keeping the dentures? In her mouth, obviously.

The denture thief was demented and apparently would not let anyone take the dentures back. So what exactly was I supposed to do? Knock her out so we could take the dentures?

To be honest, I'm pretty sure the roommate didn't want them back at that point.

Weekly Whine: Waste

I'm embarrassed to tell you how much of my day is spent in documentation. There are some moments during every day when I feel more like a secretary than a physician. But it's important to do, not just to communicate information and to cover my ass but also for the sake of reimbursement. In order to bill for my time, I have to document a certain way.

There are times when I get pissed off about the fact that I have to do all this documentation. Don't insurance companies trust me? I'm very honest. Then I hear a story like this:

A cardiologist told me that back in the "old days", he used to bill for reading arterial blood gases. Every time a patient on his service had an ABG, he would "read it" and then bill some ridiculous "reading" fee. He apparently made a ton of money doing this.

I have heard dozens of similar stories about the crazy things people used to bill for in the "old days."

Older generations of doctors: you ruined it for the rest of us.

Malignant

The place where I did my residency had a really horrible urology program. It was extremely malignant due to the program director, who was apparently always threatening to put residents on probation. A friend of mine, who I will call Angela, was having an especially horrible experience.

When Angela was in her R2 year, she was put on probation... she couldn't even write tylenol without calling an attending for approval. So she'd get called at home for a temp and she has to come in, evaluate, and then call the attending at home to find out if it's okay to write for tylenol. The rest of us could give a verbal order for tylenol and maybe some pan cultures and that's it. She had to drive to the hospital.

What happened was angela was presenting a patient and said something about the patient's code status. The director was the attending doing rounds and he went on a huge speech about how R2s don't understand code status and how they shouldn't be dealing with it, and she never finished presenting this patient. So what happened is the director never heard about the patient's primary diagnosis of a fistula because he wouldn't let her finish presenting.

So later on in the day when something came up regarding that patient he ended up looking like a fool cuz he didn't know the patient had a fistula. He went ballistic, called the R2 an inaccurate and messy doctor who presents inaccurate information. She got angry and started to talk back, and he yelled at her and said she needed to understand her place. And she was so angry that she started to tear a little, and he told her she obviously had some psychiatric disturbances cuz she obviously couldn't handle stress. He told her she'd have to undergo a psych eval and she dug in her heels and it went on like that.


And then he announced she'd have to be in remediation, and then put her on probation. Indefinitely. And then after he did that to her, he kept saying he wasn't going to renew her contract, and that she'd better contemplate not being there the next year.

That's so unbelievable to me that a person could go through all those years of schooling and hard work, just to have it ruined by one asshole.

Anthology

As you can see from the winning entry posted yesterday, I received some amazing entries to the humor writing contest. I have just barely enough to put together a little anthology of the best of them, pending permission from the authors.

If you didn't make the deadline for the contest but would like to be included in the anthology, please email me a submission. The more the better!

Medical Humor Writing Contest WINNER

Congratulations to Laura, general surgery resident, on her hilarious winning entry, posted in its entirety below. And thanks to Dr. Grumpy for the help in judging!


Standardized Patients

When I was 16, I got a job as a “standardized patient”. My neighbor worked for a medical school, and they needed standardized patients for their medical student to practice talking to. Because apparently you can make it through 4 years of undergraduate, a rigorous medical school application process, and, you know, normal life experiences, but still require formalized practice in speaking with other actual humans.

So I showed up for training, and was assigned my patient role. I was hoping for a TV-medical-show mystery type patient… some vague symptoms combined with a fascinating and intriguing back story. I expected this to be my dramatic acting debut, complete with genuine tears of pain and suffering when recounting my medical symptoms.

Instead, I was told that I was a slut. Apparently, their medical students were not comfortable talking to young teenage girls about their sexual escapades. So I was there to be a big-ole slut.

My character profile was a real gem. I worked at Taco Bell after school, and I started sleeping with my manager. He was 23 and had a motorcycle. We had unprotected sex because he didn’t like condoms. So I was looking for birth control pills. I was supposed to act embarrassed and shy, and evasive and reluctant in answering questions. The young doctors-to-be were supposed to recognize that I was at risk for STD’s and domestic violence and set me on a better path.

It was awkward. It was beyond awkward. Awkward was a dead fly on our rear view mirror. I would’ve killed for it to just be “awkward”. I had to pretend I was there for a headache, because I was too embarrassed to come out and say I needed to talk about sex. So the medical student would start on a rigorous course of questioning about my headaches to which I infuriatingly answered “I don’t know” to every questions. This charade continued until finally, exacerbated after wasting 12 of their 15 minutes on my obvious non-headache, they would ask, “So what are you really here for?!”

I got more frustrated than they did with the “headache” prologue. Sometimes I would try to make my own transition…. They would ask “Does anything seem to make the headache better?” and I’d say “Yes, having unprotected, crazy, statutory rape sex.” The doctor-teacher sitting on the other side of the one-way glass did not like that.

The other awkward part was the physical exam. In the real world, a teenager at risk for genital warts and cervical cancer would get at least a glance-over of her down-there-ness from a doctor about to prescribe birth control. But the medical school did not want their fumbling mini-doctors poking around my junk. Probably because paying a 16-year-old to let people repeatedly perform pelvic exams qualifies as a child sex crime.

But the medical students didn’t know whether they were supposed to exam me or not. In an attempt to make up for the awkwardness of the encounter up until they point, they would charge confidently ahead in stating that I needed a pelvic exam. I was supposed to tell them I was on my period, and about 80% of them got the point and backed down. Another 19% got the hint when I said I was really uncomfortable with having an exam, but promised to come back next week for an exam. Then there was 1% of medical students who still persisted. They thought the “I’m on my period” bit was like the “I have headaches” ruse, and they were too smart to fall for that twice. They were going to exam me whether I liked it or not.

Here’s a tip for medical students- if an standardized patient encounter ends with a 16 year old girl yelling to get your hands off of her, then you have failed.

All that being said, being a standardized patient was the best job you can possibly give a teenage girl. I literally got paid $30 per hour to be lectured about having safe sex. At 16 years old, I knew more about syphilis, HPV and how teenage pregnancy would ruin my life than any other virgin ever.

Once I was in medical school, it was my turn to awkwardly harass pretend-patients. One night, we had a special, after hours, standardized patient session. Instead of the usual daytime, on campus session- this one was on a Thursday night at a ‘special venue’. They even fed us dinner beforehand. Like a naïve school girl, I missed all the hints… late night, dinner prelude… things were about to get inappropriately intimate.

It started with pelvic exams. The women who volunteered to be standardized patients for fumbling medical student to learn pelvic exams on them are… um, well… interesting. One was a midwife, who was so used to seeing lady bits that she believed her own were no more personal than her bony elbows. Another was the owner of the local sex shop. She taught weekly classes like “Oral Sex 101” and “G Spot Roadmap”. She had an overly aggressive style of grabbing our hands and repositioning them while saying something vaguely sexual like, “Now twist like this, move in, push up and yes, that’s my cervix, right there!”

Male medical students were the worst. We had a very simple script were we supposed to follow while we did the exam, “OK, we’re going to get started now. This is my hand on your leg. You’re going to feel a little pressure now. Alright great, everything feels normal and healthy. We are all done.” But somehow the awkward males would manage to turn every phrase into a pseudo-sexual come-on. “I’m going in now. Oh, that feels good. I’m about to finish.” My vagina clamped down like a steel trap just listening to them fumble through it.

I can’t say that the female medical students fared much better when the tables were turned. It was fairly obvious which ladies had never seen an uncircumcised member before, as they fuddled with the extra cloaking. Do we pull it back? Do we peek inside? Is there a zipper somewhere? And how long can one spend feeling the testicles for lumps and bumps before it seems like foreplay?

The last event of the night was prostate exams, aka finger up the butt. For some reason, this was where our teachers drew the line about what it was appropriate to have the standardized patients do. So instead of feeling real prostates, they lined up a series of plastic models to practice on. Inside each butt-hole model was some different variant of a prostate, so we could learn what normal felt like, and how to recognize a cancer. The act of guessing what something is based on how it feels while jammed inside someone’s butt has never been, and will never be anything but hilarious. It’s fun for all ages!

I recently went to dinner with the attending surgeons of the colorectal surgery division. We hadn’t even received our appetizers before the conversation turned into a sparing match of who had found the craziest thing in a patient’s butt. This scenario is international, and it transcends cultures. I truly believe I could travel to rural Ethiopia, meet with a surgeon, and start showing off x-rays of things-stuck-in-colons and we would bond instantly. However, stories about things stuck in butts are like stories of the fish that got away- greatly exaggerated in every direction and conveniently never witnessed by a second party.

What physiatrists do

I had an experience in ortho clinic as a resident that was kind of a metaphor for what being a rehab doctor is all about.

In the new specialty clinic building, all the patient examining rooms had computers with printers. Apparently, all the ortho docs had been trying for months to get these printers to print out patient films, but without success. However, on my one day in the clinic, I got a patient's hip X-ray to print out. Everyone was super impressed.

How did I do it? Instead of printing from the actual radiology program like all the ortho docs were doing, I pressed PrntScrn, then I pasted it into Word and printed the Word doc. A cheap solution, but it worked.

And that's kind of what we're about. In ortho, when a bone is broken, they fix it. Orthopedic surgeons fix things that are broken. Physiatrists take things that are broken and can't be fixed, but find a way to make them work anyway. It's a worthy cause, I think.


FYI: The winner of the humor writing contest will be posted tomorrow in its entirety!

Ebola

It's sort of hard to read so much about ebola without making a post about it.

Right now, Ebola is pretty low down on the list of things I am worried about. Hell, the flu kills more people every year than ebola has ever killed ever. It doesn't seem incredibly contagious and it doesn't seem like any Americans have died from it yet, making its mortality rate in Americans somewhat less than 70%.

That said, when I heard about how Dr. Spencer, the physician who treated ebola patients in Africa, went around the city doing his thing for over a week before he was diagnosed with Ebola, it did make me angry. If you have a clear exposure to sick patients, why wouldn't you want to be quarantined? It's clear that the doctor who went to Africa to help these people is a hero and cares about people a lot, so why wouldn't he automatically take this precaution?

Yes, I do understand that a three-week quarantine is probably difficult. But at least he could've avoided going on the subway or going bowling. He could've just gone out for completely necessary things.

And yes, I know that ebola is supposedly not contagious until the patient starts to show symptoms. But what if he is contagious an hour or two before the fever is noticed? How many people could be exposed in that period of time if he is going on the subway and not taking any precautions?

It seems like we go from being completely hysterical and overcautious to completely throwing caution to the wind. That medical correspondent Nancy Snyderman was given shit and put on mandatory quarantine after running out to grab a bite to eat when she hadn't even been caring for any sick patients, yet they allowed a nurse who cared for an ebola patient to fly on a plane when she was running a fever.

Aid groups are arguing that a mandatory quarantine would cut medical personnel volunteering in Africa by three quarters. Is that really true? Dr. Spencer was in Africa for two years. Would he really not have gone if he knew he was going to have to be in quarantine for three weeks afterwards? People going to treat Ebola in Africa are risking their lives. Are these people fine with risking their lives, but wouldn't be able to handle a three-week quarantine to prevent risking more lives?

So yes, I am in favor of a mandatory quarantine if there is clear contact with someone sick. But feel free to convince me otherwise.

Weekly Whine: Been there, done that

I can't tell you how many times I have gotten an amazing idea for a blog entry. I get really excited about it, because my goal is to entertain you guys, and I'm happy when I get a really good idea.

Then I do a quick search of my blog, and it turns out I already wrote about that topic. Like, three years ago.

I have had this blog now for about five years. I have written about a lot of topics that are important to me. Most of the things that I feel strongly about are things I have already written about. Often more than once.

Obviously, new things are always happening to me and there are situations at work that are frustrating, funny, or interesting. But I am really careful not to write about anything actually happening at my job. I feel that is just asking to be burned. Usually when I say something happened to me yesterday, I mean yesterday six years ago.

So it can be a big challenge to come up with new content for this blog that isn't just same old, same old. I hope the effort is appreciated, whether or not it's entirely successful.

It's easy to be a jerk

I was recently reading an article on why doctors can be such jerks.

I wouldn't describe any physicians that I currently work with that way but I've certainly worked with plenty of jerks in the past. There are jerks everywhere, but it does seem like the percentage of doctors that are jerks is maybe somewhat higher than average.

This article talks about why doctors are jerks. The two reasons are first that doctors become arrogant and look down on their patients, and second that doctors become jerks when they're frightened or stressed out, which is obviously common in medicine.

I think part of the problem is that it's often easier to be a jerk then not to be a jerk.

For example, I was recently trying to reach a doctor at another hospital with a question on a patient. I had been waiting an hour for them to call back, and when they did, a random nurse picked up the phone, and told them that nobody was trying to reach them and then hung up, without even asking around.

I was so angry, rightfully so, I believe. It would've been so easy to snip at that nurse for what she had done wrong, and I'm sure I would've gotten away with it, considering what she had done had compromised patient care. It was much harder to take a few deep breaths and calmly explain the situation to the nurse, and then go through the process of reaching that doctor again.

Or to give a less obvious example, often when I walk onto the ward, immediately everyone descends on me with questions, before I've had a chance to catch my breath or get my bearings. It can be very tempting to snap at everyone that they need to step back and give me a minute.

Taking care of patients can be really frustrating, and it is actually really hard to calm yourself down and continue to be kind to the people around you. The staff on my unit call me the "nice doctor" because I try so hard to be nice and approachable, no matter how frustrated I am, no matter how much I feel like if somebody asks me one more thing, I'm going to punch a wall. I monitor every word that comes out of my mouth, to make sure that is not something that would hurt another person's feelings.

You'd think that would be easy. And some days it is. But many days, it is a real challenge.

Dr. Orthochick: The Hoarder

The nurse walked over to me and said "just to warn you, the woman spells like cat pee and human pee and the house they found her in looked like it was out of Hoarders. And we don't know why she's here, even though her son is with her and he lives with her. I think she might have fallen."

This 75 year old lady actually did smell like many different types of pee. I'm not sure which species were represented, but i'm pretty sure half of the domesticable animal population had left their scent on her. In addition, there seemed to be a few days' worth of human pee as well. Because that's not gross enough, when I asked her to roll to the side so I could listen to her back, I discovered her back was covered in dirt. And little twigs. And dead leaves. As far as I could tell, she had been lying in filth for days. I asked her what happened but she told me to mind my own business. Then she said she was at walmart that morning. I asked the son if she had, in fact, gone to walmart that morning, but he said he didn't know. So I decided to try and get the story from him.

me: OK, so what happened?
Son: What?
Me: I heard that your mother fell?
Son: Did she?
Me: Do you live with her?
Son: Yes
Me: So what happened?
Son: I don't know.
Me: Why did you come to the emergency department?
Son: What?
Me: WHY ARE YOU HERE?
Son: I don't know
Me: OK, let's talk about this morning. Why did you call an ambulance?
Son: I was going to take her to a checkup but the ambulance brought her here.
Me: Why were you going to bring her in an ambulance? Is she not able to walk?
Son: She says she can walk
Me: Can she?
Son: I don't know
Me: Well...don't you live with her?
Son: Yes
Me: So...do you see her walking?
Son: I don't know.
Me: OK, when was the last time you saw your mother before this morning?
Son: I think it was a week ago. I don't know.

I gave up, did a full trauma exam on the woman, which probably exposed me to every pathogen present in pee (and yes, I know pee is sterile, but that's only when it's in the bladder. On its way out the urethra it gets exposed to a ton of bacteria) and also got dirt all over my hands and stethoscope. She had bedsores on her hips and she couldn't raise her arms above her head or lift her feet off the bed. (The son said "she's pretty strong" after observing his mother's inability to lift her legs) She looked pretty dehydrated. So we ordered the standard "patient fell" workup (pelvic and femur x-rays, chest x-ray, head CT, EKG, bloodwork) and called internal med to admit her.

My attending also ordered carbon monoxide levels on her after hearing about the level of acuity demonstrated by the son.

I don't really know what's going on, but this looks like elder abuse. Or, at the very least, elder neglect. I'm not saying it's intentional because the son didn't seem to have two brain cells to rub together, but it's a little scary how people can fall through the cracks like that. I tried calling the last PCP she had and he said he hadn't seen her since 2005. I found an ER report from December in a different city where they noticed her appearance and filed a complaint with adult protective services, but that means that there's a good chance this woman hasn't been out in public for 5 years. Clearly she doesn't have a competent caretaker, and I'm guessing she hasn't been getting her meds since neither she nor the son could tell me what they were. And I didn't see the house she was living in, but judging from her appearance, it should be condemned. So you have her and the son living together in squalor and no one else knows/cares and so no one gets her (them?) help.

The Inevitable

I have a couple more, but they're pretty silly/NSFW. I can't decide if I should post them or not.

Weekly Whine: Me

Some of you may or may not remember my story where I got into a fight at Kmart over a pair of sunglasses that took me half an hour to buy. This is part two.

About a week after the Kmart situation, Mel and I went to the Painted Penguin chain. It's one of those stores where they have pottery that you can paint. It's one of her favorite places to go and we had a little time alone together, so I took her there.

The pottery is organized on the wall by price. You can pay anything ranging from about $10-$30. Considering I knew the pottery would either end up in a drawer or broken by her baby sister, I told her to pick something from the $10 wall.

After some deliberation, Mel picked out some Pokémon pottery. We went to pay for it, and it rang up about five dollars more than I thought it would. I thought it was probably some sort of surcharge they had added, so I casually asked about it.

Cashier: "this pottery came from the $15 wall."

Me: "no it didn't. We got it from the $10 wall."

Cashier: "well, maybe somebody put it back in the wrong place. But it's a $15 pottery."

Me: "but it was on the $10 wall."

Cashier: "I don't know what to tell you."

Obviously, I don't care about an extra five dollars. I had been perfectly willing to pay it when I thought it was a surcharge. But the whole thing pissed me off because I had gotten it in the right place and it was their fault that it wasn't where it should've been. It's their responsibility to make sure pottery gets put back in the right place. What's the point of the walls if they mean nothing?

I told Mel that we were going to pick out a different piece. I mean, it's not like that stupid Pokémon pottery was so wonderful. But apparently it was, because she started to cry. So I had to suck it up and buy it.

I couldn't resist saying to the cashier, "you know, this sucks. The pottery was in the wrong place and now my kid is crying, so what am I supposed to do?"

But I was pretty much talking to hear myself speak at that point.

Anyway I got over it, and Mel painted her Pokémon. Then afterwards, we went to the supermarket. They had a little bin of beanie babies, which were marked down from $8 to $2.

Mel asked if she could get one, and I told her she could. And I figured we had to get one for her sister too, otherwise there would be major jealousy. So we took two beanie babies and went to pay for them at the self checkout.

Naturally, the second beanie baby rang up as eight dollars.

But here's the reason I'm writing about this. The second I saw the beanie baby ring up as eight dollars and commented on it, Mel said to me, "mommy, please don't get angry!"

And that made me feel really bad. I mean, I don't think I was wrong in either of those situations, but I hate to think that I'm getting worked up enough that it's upsetting my daughter.

Yet at the same time, I'm not just going to sit there with a smile when I'm getting shitty customer service.

(In case you were curious, I called customer service over and ended up getting the second beanie baby for free for some reason.)

Doctor Finder

A little while ago, I was calling to arrange a patient cardiology follow-up after her discharge. (Yes, my job is very glamorous.) I called the hospital she had come from and the operator informed me that there were no cardiologists on staff there, and anyone who had seen her had just popped in for a consult.

Me: "so how am I supposed to get her seen by cardiology?"

Operator: "well, I could put you through to Dr. Finder."

Me: "he's a cardiologist?"

Operator: "…"

Me: "sorry… Is that a she?"

A minute later, the operator had put me through to Doctor Finder, a service for helping you find a doctor. Talk about feeling dumb …

Choice

I recently wrote a post about the interventions that should or should not be done on elderly people. One complaint a lot of people had is that they didn't want the decision to be taken out of the hands of the patient or the family. I would like to share a personal story about why I think it should.

When my favorite grandmother turned 80, she started to develop dementia. It happened very quickly. In a matter of months, she went from the woman who used to make me all my favorite foods and discuss books with me to having weird delusions and hallucinations. She was not pleasantly demented. She became very confused, agitated, and emotionally labile.

Eventually, my mother had to put her in a nursing home because she could not be left alone anymore. She didn't receive horrible treatment, but she never seemed very happy, which was probably due to the many small infarcts that caused her dementia. Every time I talked to her she would start crying.

About four years later, she suffered a massive hemorrhagic stroke. The doctor told my mother that on the scan of her brain, "there was more blood than brain."

For reasons beyond my control, she had been made full code. The doctors told my mother and my uncle that there was essentially a zero chance of any sort of meaningful recovery. But because they had the option, she had a craniotomy to remove some of the blood from her brain followed by a tracheostomy and feeding tube placement.

She never again regained consciousness and died on a ventilator a few months later.

My mother knew that there was no chance of her recovery. The doctor knew it, I knew it, everyone knew it. But because she was given the option to keep her mother alive, she felt she had to do it. I couldn't talk her out of it.

Meanwhile, I feel like my grandmother was robbed of the dignity of a quick death from a stroke.

Why are people given a choice of a procedure that has essentially no chance of working? At least in her case she was unconscious through the whole thing, but plenty of people spend the rest of their short life in agony due to treatments they never should have been offered.

Some people may say it's heartless, but I think sometimes the most humane thing is taking away that choice. Of course, nobody likes feeling that their choices have been taken away. So I propose a system where the patient can choose to act in their own best interest:

I think when people get to a certain age (75?), they should be offered an option for a quality-of-life based healthcare insurance. The insurance would not pay for an ICU stay, being intubated, CPR, major surgeries that are high-risk and expensive, cancer treatments that are not palliative… You get the idea. Instead, the insurance would provide services that would improve quality-of-life, such as extended hospice services or nursing services to come to the patient's home (this exists now, but isnt good enough yet to keep many people out of nursing homes). Considering how much money is spent (wasted) on extending the life of elderly people for short periods of time, I think the insurance companies would jump at the chance to do this. Plus it would keep people out of nursing homes, which I genuinely think most elderly people fear even more than death.

Then when it comes to those risky procedures, that choice is gone, and you were able to use your health insurance for things that actually made your life better.

Contest Deadline TOMORROW

I know people in medicine love to cut things down to the wire. Entries for the First Annual Medical Humor Writing Contest are due tomorrow! I will allow submissions until midnight tomorrow, in whatever time zone you live in.

Dr. Orthochick: Back surgery

Dr. X paged me while I was operating so I called him back after I was done.

Dr. X: I have this patient in room 321, I did a [spinal] fusion on him the other week. He fell and now he can't move his legs. We got a CT scan and it showed a T3 fracture. So I want to extend his fusion. I need you to explain to him and his mother, who's an idiot but she's his legal guardian, that he may have a spinal cord injury and could be paraplegic and then I need you to get consent for the surgery. Oh, and make sure they hold his heparin tomorrow.

Oh. OK.

Just to recap, that means I need to go talk to some patient who I've never met and know nothing about and tell him that he may be paralyzed for life. Then I need to explain to him that he needs more surgery. I need to convince him and his mother. I've never met this guy before. I don't really understand what's going on. I have nothing to do with any of this.

Seriously people, do your own damn dirty work.

So I went to talk to the patient. He seemed a little slow in that he was having a conversation with the phone while it was ringing, but he definitely understood what I was telling him. As in, I walked in and asked him how he was, he said he was terrible because he couldn't move or feel his legs, I said we wanted to do surgery to fix the broken bone in his back and he said "Oh G-d no, not more surgery. I'll do anything but that." Then he started crying. Because I have no tact, I pushed forward and I said we wanted to also look at his spinal cord while we were operating because there was a chance that whatever it was that was causing his paraplegia could be reversed. The thing is though, that's probably not all that accurate. So I had to say that there was a good chance if he was paraplegic now, he would always be paraplegic. I think my exact words were "It's likely that you will spend the rest of your life in a wheelchair."

He understood that.

Then, because his mother was his power of attorney, I had to call her to get permission for the surgery. She understood what was going on after I told her that he might never walk again. She said 'it sounds like he might not be able to walk again even if he has the surgery." I said that was true. She said she was still OK with him having the surgery. So I got consent, called the primary team to tell them the plan, and made sure he was appropriately pre-opped. The whole thing took about an hour.

See, this really does not sit well with me and I was actually pretty pissed about the whole thing. I know I tend to be more anal than most people when getting consent because i don't want a surgeon who can't sit down with me for two minutes and explain the surgery and the risks and benefits and I get that not everyone is like that and it's fine, but I really think it's inappropriate to have someone else deliver bad news to your patient. I mean, I don't think anyone enjoys telling people that they'll never walk again (and this is my second time in a week and really, the experience has not improved with time) but I feel like if you're the one who has the relationship with the patient, you should be the one to tell him. I don't think it's fair to the patient or to me to stick me in this position. I don't know anything about the patient or his history, so I really can't answer any questions. He doesn't know anything about me, so why would he trust my opinion on anything?

The patient said "I wish I'd never had the first back surgery." It was hard to argue with that logic so I slunk out of the room while he and his mother cried together over the phone.

It's really hard being a surgeon sometimes.

Die at 75

I was recently reading an article written by a guy who said he wanted to die at 75 years old.

I thought for sure I was going to disagree with every bit of the article. There were definitely parts that I didn't agree with, such as foregoing some basic cancer screening. (I think I would do anything to keep from dying of colon cancer.) I don't agree with the basic philosophy, that once you slow down significantly, life is not worth living. Plenty of people over 75 have wonderful and worthwhile lives, even if they can't do with they could do when they were 30.

That said, with the aging population, I do think medical treatment to people over 75 (to set an arbitrary cut off) should be limited.

I do think the elderly should have access to antibiotics, flu shots, and medications, and should see physicians frequently. But nobody in their 80s should be allowed to be full code. It just doesn't make any sense in terms of expected recovery. Furthermore, I think cancer treatment should be palliative only at that point. Any major surgeries, such as a bypass surgery, should be avoided. Nobody over that age should be allowed to have a trach or feeding tube. The chances of recovering and having a reasonable quality of life after these interventions is just not high enough to justify it. Frankly, I think it's just cruel to the patients, in addition to being a waste of medical resources.

The most important thing is that the decision ought to be taken out of the hands of the patient or family members. It feels so ridiculous when we ask a 90-year-old if they want to be full code. A lot of the time, the patient or family will say yes, because they just don't understand what it means. They think not being full code means we won't treat their family member, but what it really likely means is it their family member will not have to die on a ventilator. Or alternately, they do understand what it means, but feel guilty making any other decision. I am still angry with my mother for putting my grandmother through a "life prolonging" surgery instead of withdrawing care when the doctor essentially told her there was no chance of recovery, but she said she felt guilty doing anything else.

For starters, I think everybody over the age of 80 should automatically be DNR. And we should seriously consider what other medical interventions should be offered to people who most likely won't benefit from it.

Weekly Whine: Short Season

Lately, my husband and I have been watching some new TV shows. A couple of the shows that we really like are Nathan For You and the IT Crowd.(Well, I like the latter. I'm always a sucker for an Irish accent.)

When you start watching a show and you think that there are four seasons to watch, it makes you think that there are lots and lots of episodes. But somehow, in these shows, the seasons are only five or six episodes long. It's kind of a cheat.

Seriously, how is it possible to have a show with only six episode in the entire season every single season?

A doll that poops!

I would have thought this was a joke, except I saw it in a commercial on television:



Basically, you give the doll water to drink, and then it poops out a charm in its diaper. And then you wear the charm around your wrist.

Because as everyone knows, little girls are dying to wear poop bracelets just like their mommies.

There's still time!

For those of you who have been procrastinating, there is only ONE WEEK left to submit an entry to the First Annual Medical Humor Writing Contest. The $25 Amazon gift card is still up for grabs!

Dr. Orthochick: You are fat

The government is into preventative medicine or something like that these days, so if you go to your friendly local orthopod's office, they have to ask you about your most recent mammogram, your sexual history, and your vaccination status. Technically they don't, but the way funding is set up, they get reimbursed more if it looks like they care about the patient as a whole. In addition, we are now giving out what we refer to as the "you are fat" handout. The "you are fat" handout goes to anyone with a BMI>25, which is technically overweight going by the BMI calculator (as in, not taking muscle mass into account, etc) but it's not fat. Or at least, it doesn't have to be. Not only that, but you have to give it to a patient each time he/she comes to your office. I guess to make sure they know they're still fat. There's a second "you are fat" handout that you get if your BMI is over 30, which I believe is "obese" if we use the BMI scale. Your office gets reimbursed more if you show you're giving out the "you are fat" handout so we're all doing it these days.

For obvious reasons, I am not a fan of the "you are fat" handout. I mean, I feel like I wouldn't go back to a doctor if the first thing he did was give me the "you are fat" handout. From what I hear, I am not alone in this regard. Apparently there was a 20 year old who started crying hysterically upon being presented with the "you are fat" handout. They haven't seen her since. Also, most of the attendings are really not all that thin. Dr. Orthoking Jr probably weight around 300lbs, so I can't imagine anyone would take the "you are fat" handout seriously if it came from him. He's probably the fattest, but there's a whole pile of them who really aren't so thin. So I'm not sure how seriously I would take the "you are fat" handout if it was coming from someone who was, uh, fat.

Also, the "you are fat" handout is causing me some distress and I haven't even gotten it. The other day in the OR, Dr. Chatterbox was talking about it and he said "I bet everyone in this room has a BMI over 25!" That seems like the wrong thing to say in a room full of women. He then said 'I think everyone in my office has a BMI over 25...well...maybe not the new girl." So I had to calculate my BMI after the case to see if I was, in fact, over 25. I am not. I calculated what my weight would have to be for me to be 25 and I am below that by a wide enough margin that I could go to the all you can eat buffet tonight and then I could still be under 25 tomorrow morning. (I do not think I could do that more than once, however) But still, I don't want my attending to think I need the "you are fat" handout because, like I said, I'm a little bit touchy about it.

Today the "you are fat" handout was mentioned again and I said I had calculated my BMI and I was definitely not over 25 and Dr. Chatterbox said "oh, so what are you? #?"

...and...I got a great evaluation today in the OR. And it has nothing to do with Dr. Chatterbox feeling bad about overestimating my weight by the time I was done. I totally deserved all those "excellents."

Key

Is it better to keep a spare key in the house or in your purse/bag?

Chemistry lab fun

Weekly Whine: Surveys

I really hate people who call you on the phone to do surveys.

I used to feel sorry for those people. I mean, what a crappy job. So one day, when I had a little bit of time, I agreed to do the survey.

I felt that my goodwill was completely taken advantage of. I answered a few questions, but the questions wouldn't stop. It was getting to the point where my answers were completely irrelevant because the questions were stupid and I was so angry at that point.(The questions involved my rating movie after movie after movie, most of which I had never even seen.)

What was worse is that after I finally told the person, as politely as I could, that I was not going to participate anymore, the number of calls I got seemed to triple. Like I got put on some sort of sucker list.

I insist on having a landline for emergencies, but the only calls we get on the landline are from telemarketers or people doing surveys, despite being on a no call list. We eventually just turned the ringer off. They have basically rendered our phone nearly useless. I hate those people.

Med students are people too

As a med student on surgery, I had to go to this lecture after my seven straight hours of ambulatory. I was exhausted, my neck was killing me, and the only thing I had eaten all day was a couple of handfuls of peanuts. Still, I went to this lecture.

Only when I got there, it was in this small classroom and there were no available seats. There was this resident sitting in the back and I tried to ask him if there was a seat next to him, but he was unresponsive.

Then another surgery person came in and the resident actually got up to give that guy his seat, still pretending that I didn't exist. I was more than irritated at this point, but I couldn't leave, so I sat down on the floor. The resident had left his coat in the room and as he was reaching to get it, something fell out of his pocket and landed behind my back. I didn't know what it was, but I quickly moved backwards so that he wouldn't be able to retrieve it without asking me to move.

The resident disappeared for a minute and I checked what he had dropped. It looked like a laser pointer. I stuffed it into my pocket. Subsequently, another female medical student came in and had to sit on the floor also.

Then the resident returned with a chair! I thought, "How nice, is he trying to get us chairs?" But no, he just brought the chair for himself.

And I got to watch the bastard searching through his pockets for his laser pointer when the lecturer called on him to read a CT. Yesss! It was a drug company laser pointer anyway, the sellout.


---


For those of you who have been procrastinating, there are only two weeks left to submit an entry to the First Annual Medical Humor Writing Contest. The $25 Amazon gift card is still up for grabs!

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.

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.

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."

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.

Rear View

My brother made this one:

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?'