Hurricane Jill

Well, that was awesome.  Superbowl XLIV brought tears to my eyes.  Although it did NOT make me want to move back to NOLA, even if they did just elect Mitch Landreiu.  Which they should have done four years ago.  But I’m happy the Saints won, and happy for all my friends who still live there.

As for me, somehow I managed to contract food poisoning last night, and couldn’t keep anything down until about 4pm today.  Things are still pretty iffy, even now.  So I didn’t get to go to any superbowl parties.  Oh well.  At least the Saints won.

So, back at the VA-spa for a couple of months.  Possibly longer if events transpire as we all expect.

There’s a lot of downtime at the VA, so I’ve decided to use it to create a bunch of presentations.  I’m calling it the junior resident series, and it’s as much to educate myself as anything else.   Plus, someday hopefully I’ll be a chief resident, and it’ll be my job to teach the residents behind me how to do things well at whatever level they are.  And wouldn’t it be nice to have a bunch of canned talks ready to educate the juniors in a more formal way about the fundamentals of neurosurgery?  No matter where I end up, it should be useful.

Premature?  Sure.  But then again, this kind of planning ahead is exactly why my house in NOLA survived Katrina without flooding, and why I took everything important with me when I evacuated.

Every neurosurgery service needs at least one blue-eyed, blond-haired female among its residents and attendings.  I am probably going to be tarred and feathered by my female colleagues for making this point, and yet I doubt anyone could truly deny it with a straight face: most males 15-50 who are in any way conscious and processing visual information are going to have a better neuro exam for someone they find attractive.  Which by conventional standards in our society is the blue-eyed blond girl.  If they’re capable of regarding and tracking, they’ll do so.  If they can follow commands and talk, they will.

The same can be said of female patients and male doctors.  But the fact is that most trauma patients are males 18-35.

I’d always considered looks more of a liability than an asset for women in this field.  You know, the whole, “why do you feel it necessary to do this kind of grueling, depressing work when you could easily have married well, and be off having smart, good-looking children while your husband earns a living instead?”  Nobody really gets it, and frankly I ask myself that question as well.  There’s no rational answer.  Other than that I like to work, and no guy has yet convinced me it’s a good idea to have kids with him.

I’m not against the idea of kids in principle, but I’m not having any unless I also have the resources to raise them well.   End of subject.

Anyway, I’ve noticed that with certain patients, the nurses and I routinely get better exams than the male residents do.  And not just that, I’ve noticed that I get better exams when I wear my hair down than when I wear it in a ponytail or up in a bun or twist.  It’s actually kind of funny, and on a couple of occasions recently I’ve been sent in to see patients in that demographic who won’t respond to any of the residents.  But I can get an exam.  I don’t fool myself that I’m any better at examining patients than they are–it has absolutely nothing to do with skills or knowledge.  But at least I’ve finally found an acceptable use for the blond hair and blue eyes.

My last call was… how shall I say it?… interesting.  We very nearly won the game, at least with respect to the floor patients.  And the ICU portion of the service was relatively small and stable. But contrary to what you might think, it is actually not at all desirable to be going into a call night with a small service.  You see, the limiting factor on the size of our service is not the supply of patients who need a neurosurgeon, but rather the availability of ORs and nursing staff for the ICU.  So all that a small service means is that the on-call resident can get that many more hits before the on-call attending has to stop accepting transfers from the remote corners of our catchment area.

And then, of course, there are always the patients who come in through our own ER and need to be evaluated.  The yield is somewhat lower for these, with respect to problems that might actually be operative and interesting.  But they still have to be seen and recommendations made for treatment or follow up, or potentially admitted for observation.

And for whatever reason, that night we also had several old-school pre-op admissions, where they come in the night before surgery without any labs, studies or even the H&P, and all those things need to be done and reviewed by morning.  These days all of that is usually done at a clinic visit beforehand.  The patient shows up the morning of their surgery, and comes to the floor or ICU postoperatively.  It involves a great deal more cat-herding, in terms of handoffs, coordination of care and paperwork to do it the way we do now, but it minimizes hospital room charges, which by the usual accounting practices is more cost-effective.  If we could somehow quantify those intangibles, as well as resident learning and an overall less frantic pace and fragmentation of planning and preparation for surgery, I think that might not be the case.  But the last 20-30 years’ focus on cost-effectiveness and patient safety in hospitals has come at the expense of medical education and training. Residents are cheap labor, and one role of a good residency program is to keep the service component of residency subservient to the learning and teaching components.   An unintended consequence of all this concern over money has been a significant decrease in resident autonomy. You can’t bill for services if the attending wasn’t directly supervising.  Not to mention the public outcry over the idea that a resident may actually be directing Grandma’s care over at the county hospital, without significant attending supervision. This kind of fearful overprotection has paralleled the trend in parenting over the same period: how can kids learn to make good decisions when their parents are constantly hovering, ready to rescue them and fix all their mistakes?  Helicopter attendings are the new reality in medical training, and current rules encourage them to be that way.  They literally can’t let the residents make their own decisions, even if they want to.

Frankly, I like the old-school system better, as painful as it makes a modern-day call night.  I felt like I knew those patients better in the morning, because all their clinical information was coming at me when it was immediately relevant, and I could link all the parts together into a coherent whole of what we were doing and why, rather than getting the information weeks ahead of time when I’m just checking off boxes to be diligent, and may or may not be the one who actually needs it.  The way we do it now is not conducive to adult learning.  And no matter how young some of us are when we start medical school, by the time we graduate we are all adult learners.

Anyway, we have a few attendings who seem quite good at letting us drive the bus overnight and then pointing out the cliff we were dangerously close to (or on occasion drove over) the following morning, all without compromising patient care in any significant or permanent way.  It’s amazing how much more you learn when all you have is a cushion to prevent serious injury, rather than a net to keep you from hitting the ground at all.

Today’s fortune: Often, the definition of success is just hanging on after all others have let go.

I’ve found this to be very true, and why success is often not as satisfying as we expect it to be.  It makes you wonder whether you’re just the idiot who was too stupid or stubborn to reconsider, and is now left holding the bag.

First post from the new computer.  It went fairly smoothly, with the exception of transferring my iTunes files.   I still can’t figure out how to do that, and I think the main problem is that my old computer was just too old to run the latest few versions of iTunes well.  And you have to be able to set up the transfer correctly on the old computer in order to move all your files to the new one.

The only annoying thing is that all my old photos are now distorted in that particular way that HD displays distort regular definition TV.  I wonder how to fix that?

This computer is over 10 years old now.  Although I replaced the hard drive about 6 years ago, so maybe it’s officially only 6. Who knows?  I bought the exact same hard drive configuration, so I say 10.

Either way, it’s served me remarkably well, and for far longer than I expected.  I did a lot of research into the various kinds of hardware components available at the time, and bought it from one of those places that will let you select each component separately, and totally customize your computer.  So I was able to get something that would stay current–at least for my anticipated uses–a bit longer than the average 3 year lifespan.  After that, it was just a matter of not minding too much if it ran a little slow, and could only run two or three applications at a time without freezing up.

But when I can’t run Firefox and iTunes at the same time, that’s where I draw the line.  And it’s been like that for about 6 months or so now.  At first I was waiting for Windows 7 to come out.  I’ve been running XP for a decade now and would like to continue the pretense that there’s no such thing as Vista.  Then I couldn’t find a computer I liked.

It’s pure commitment-phobia.  I would go to Costco, and see a whole host of affordable, up-to-date, perfectly good computers.  And I’d stand there dithering around, comparing them all, liking one thing about one of them, and something else about another, but not finding any with everything I want except ones that are overpriced and cluttered with all sorts of other gadgets and gizmos and programs I don’t want.

It’s quite the metaphor, now that I think about it.

I hadn’t even been able to decide between a desktop and a laptop.  My laptop is totally dead, but I really want to replace it with a netbook instead of another laptop.  And I can’t justify buying a netbook when what I really need is MORE power and functionality, not less.  So, I finally decided, desktop first.  Then when Google comes out with their OS next fall, if it’s any good, I’ll buy a netbook at that time.

So having made that decision, I was surfing around yesterday looking at what’s out there.  Still not entirely liking anything I saw.  You know, lots of memory but a low-end processor, or good memory and processing speed but still running Vista, or a crappy graphics card, or a high-end graphics card but a stingy hard drive.  Yes, I’m picky.  When I buy something, I want to be happy with it, and not wonder if maybe that other one would have been a better choice.

Fortunately there are several companies that will still let you customize your computer, so I ended up going to one of them and just building what I wanted from scratch.  It was much cheaper this time around, thankfully.  And I got everything I wanted–or at least, as much of what I wanted as I was willing to pay for–and just as importantly, nothing that I didn’t want.

Sadly, this only works with computers.  But at least my computer and I will live happily ever after.

For once, I’m neither happy nor sad to see the year end.   2009 was kind of blah.  Which I guess is not so bad in a life like mine, where the boring and conventional are in short supply.

It really hasn’t been a good year, although there have been far worse.  It was much closer to the middle of the scale than to either end, really.  I’ve learned a lot of new things, and met a lot of new people.  I even managed to meet a few who didn’t remind me of someone else I’d met before.  But it hasn’t gotten me closer to any of my major goals in life.  I feel like I’m just treading water, waiting for the arrival of that epiphany I can sense just over the horizon.

I don’t have any new year’s resolutions.  The things I need to do require substantially more dedication than the average new year’s resolution, so the whole idea that changing one particular detail of my life will make all the difference is kind of a joke.  Plus, new year’s resolutions imply that there’s something you dislike about yourself and want to change.  And I don’t actually want to change myself, I just want to be the best version of myself that’s humanly possible. Which involves a multitude of small choices, every day, rather than any single big poor decision.

Yeah, I try to set the bar low like that.

Recently we had a patient come in brain dead after a severe injury.  (There have been lots of these admissions, so I’m not really giving away much, HIPAA-wise.)  To be honest, there was zero chance of survival, so I’m not really sure why the patient needed a level 1 trauma center.  Certainly the organs would have a better chance of viability, however it was obvious that the patient would not be needing them himself.

But we couldn’t declare him brain dead yet because he’d been sedated and paralyzed for intubation, and had other drugs on board from before the injury.  In addition, he was hemodynamically unstable on arrival, so I found myself in the very cognitively dissonant position of trying to save him so that we could declare him dead.

It seemed like a very slippery ethical slope, since it was clearly a non-survivable injury, and no intervention of ours was going to change that.  But he was a potential organ donor, and so I felt obligated to do what I could to preserve that status until he was officially brain dead and organ services could talk to the family about donation.  I just couldn’t bring myself to say that to the family in so many words.  It felt like a betrayal of their trust.  Looking back now, I think I should have.  It would have been better for them to know that our efforts were not really to save their relative, but rather in the hope that they would allow his death to save several others’ lives.  But we’re always told that we shouldn’t be the ones to broach the subject, that there should be a bright line between our role of trying to save the patient’s life and that of donor services.

Even though most of the time, there isn’t, the situation is usually muddy enough that we can cling to that fiction without too much intrusion of reality.  This time it was quite clear.

I went home that day feeling a little tarnished, ethically.

The unfortunate thing about taking two weeks of vacation is that the payback is two weeks of q2 call.  Because it’s not the actual schedule that matters, it’s the average over your time on that service.  Fortunately due to some internal program politics not involving me, one of my days got reassigned to someone else and I had an unexpected weekend day off.  I have to admit it was nice.

But overall, q2 call – at least the kind where you really do work 30 hours or less – is not that bad.  Basically you work 30, go home for 18, and come back for another 30.  And repeat.  And repeat. And repeat.  It’s more sustainable than I would have guessed.  Of course, you can’t have much of a life outside of work.  However, I find q3-4 call just as disruptive socially and yet less of an excuse for not having a life.

In fact, if we’d been working with anyone other than the person actually assigned to be our critical care attending these last couple of weeks, it might have been truly enjoyable.  I do my best not to be obvious about the fact that I prefer to work with some of our critical care attendings more than others.   But I’m human, and I’m sure it shows.

The nicest thing about family is that you can tell them exactly what you think about everybody else in your life, without concern for how your opinion would reflect back on you if your colleagues somehow found out.  From which you can safely infer that there’s a whole lot more going on in my head than I feel comfortable talking about either here or at work.

I never forget that I’m not truly anonymous here, even if the vast majority of my readers have never met me, and have little to do with neurosurgery.   All you have to do is look at the page view statistics to know that the minute I say something the least bit gossipy or potentially scandalous, word somehow gets out and suddenly I have 10 times the usual number of visitors.  So I’m extraordinarily careful these days.

It’s probably commentary enough, that I feel it necessary to tread so carefully.

In any event, it was nice to get all of it out of my head, finally.  Some days I just really hate the culture of medicine, and particularly medical training.

On a related note, I’m appalled at the lack of thought that my mom’s primary care doctor has given to the prescriptions she writes for my mom.   My mom is on a fixed income, and is currently in the Medicare “doughnut hole” of prescription coverage.

(For the uninitiated, this means she has exhausted her basic prescription coverage, and now has to pay 100% of the cost of her prescriptions until she reaches some expenditure cutoff, and then Medicare will pay again.  Medicare Part D is possibly the most idiotically designed public policy I’ve seen in my lifetime.  In fact, I’m reminded of this classic cartoon (click to zoom):

Somewhat like the legislative process

Although I anticipate that health care reform will be worse–my only question, in deciding whether to support it or not, will be whether it’s worse than what we currently have, and I think that would be difficult to accomplish.  I guess that depends on how you define “worse,” though.  In my view, worse means more physician paperwork for less actual care provided and fewer people covered.)

Anyway, back to my point.  All of my mom’s prescriptions are for medications with no generic available, with the exception of one (which happens to be the single agent in its class).  To make matters worse, one of them is a total scam product, where the pharmaceutical company took their prodrug that was coming off patent, lopped off an inactive functional group, and is now selling the metabolite as a whole “new and better” agent for the exact same indication.

Now that, just by itself, is enough to make my head explode.  Seriously, any PCP who would prescribe that to a retired person living solely on Social Security should have to buy it themselves every month for every patient they prescribe it to, and pay the cash price.  Then watch how quickly they learn not to be pawns of Big Pharma.

Then the other major medication she’s on is one of a class of second-line agents (for which there are no generics yet) for patients who don’t tolerate therapy with the first line class of drugs–all of which are available as generics.  And you can guess the rest of the story…she’s never been tried on the first-line agents.

AAAARRRGGGHHHHH!

Not to mention that her PCP is a D.O., who as a group pride themselves on their primary care training and holistic approach to patients.  So I figured she’d be in excellent hands.

And then I find out that she’s paying $500 a month for her prescriptions.  And in fact is trying to skip days here and there so that she can get to January (when she’s covered again) before she needs refills in order to pay for some much-needed maintenance on her house.

And her daughter is a doctor. Of medicine AND pharmacy.

If even she can’t get anything besides cookie-cutter, Pharma-driven primary care, I can only imagine the kind of reckless prescribing other people’s parents are dealing with.

Seriously, some days I wish primary care could be pickier about who it trains.

My most recent call night was one of the easiest I’ve had since I started here.  Not because nothing happened (it was actually quite eventful), but because I knew what to do about everything that did happen.   Also because the calls I got involved, for the most part, real problems.  Our floor nurses are notorious for hammering us with pages about clinically unimportant issues, simply because they feel neglected.  So “crying wolf” is always on the differential.  But for whatever reason, this last call night I somehow just knew the problems were real.

Parenthetically, this is why I like EMRs when dealing with floor patients.  Nothing surprises the floor nurses like YOU calling THEM about an issue before they get a chance to page you.  Not that I’m able to do that often, as the ICU and ER patients generally take up all my time.  But it’s fun when I can.

Anyway, that night was a steady stream of badness, all across the hospital.  First, we got a subarachnoid hemorrhage that actually turned out to be aneurysmal.  It’s always more satisfying to find an aneurysm, because at least then there’s something we can do about it, besides just sit around twiddling our thumbs with medical treatments, waiting for the patient either to get better or go into vasospasm.  I also like spontaneous subarachnoids because they’re an automatic two-fer, procedurally, since they all  get an arterial line and a central line.

The poor lady’s husband was beside himself with worry, though.  I nearly cried, myself, while I was getting consent to clip it.  Mostly because I had to bring up all the complications that could happen, and was unable to reassure him beyond saying that her surgeon was excellent and that we would do everything in our power to ensure the best possible recovery for her.

And then another patient who was scheduled to be discharged to rehab the very next day developed a massive hemorrhage, and lost all brainstem reflexes within an hour.  She had been talking on the phone to her husband just a couple hours prior, and then she was comatose when the nurse came in for her next neuro check.  Another difficult family conversation.

Then  another patient had a urethral injury due to inadvertent traction on his Foley catheter at some unknown recent point, with about 2 liters of hemorrhage into his bladder.  It presented in a benign manner, with somewhat decreased urine output, but not below the 30mL/h threshold that triggers clinical alarms. But it had become bloody as well, for no apparent reason.  So I asked the nurse to flush the tube, and she reported back that she was only able to get a small amount of output after doing so, and that it was full of clots. She then scanned the bladder and found >500mL of volume still inside, and noted that he was bleeding around the Foley.  So I came over to examine him, and found that his abdomen was also very firm and distended (I know, a neurosurgeon actually examining an abdomen…surely a sign of the coming apocalypse).  It was definitely time to call urology.  So I did, and the urology resident came over, made sure the bladder wasn’t ruptured, took out the Foley, placed a Coude, and irrigated the bladder until all the blood came out.  Thank God that nurse caught it when she did.

And then two peds patients with head injuries.  One, the teenager, was not seriously injured but was dramatizing the concussive symptoms a bit.  (When you deal with the whole spectrum of deceit, from simple disingenuousness to outright lying,  as you do in retail pharmacy, the BS sensor gets very acute.)  I decided to let it go, as we would be watching him overnight regardless of his mental status.

The other pediatric patient was seriously injured.  It was unclear at the time I left how serious the injuries were, but to me they did not seem serious enough to require surgery, or to result in diffuse axonal injury.  But anytime there’s a child involved, people get excessively worked up over it, and I’ll admit the mechanism of injury was quite dramatic.

On a more mundane note, we are all still adjusting to writing our notes electronically.  Some are adapting more quickly than others.   Despite the system being the same as at UW, this place hasn’t developed any note templates  to automate things at all.  So we each have to make our own templates, and every day we have to manually import the latest vitals, meds and labs.  IMHO, this is a direct result of having an IM person in charge of implementation.  Those medicine people have a much lower patient-to-resident ratio than we do, and they have much more time to write their notes, as well.  Our usual MO is to write notes and round as quickly as possible, so we can get to the OR/clinic/bedside procedures/whatever as quickly as possible.  The extra time required to write notes and import data by hand doesn’t affect their ability to function effectively nearly as much as it does ours.

Meanwhile the VA remains as slow as ever.  I feel a bit guilty being over there, knowing how short-handed it leaves the university hospital.  But I’m getting a lot of studying done, and my current goal is to be able to distinguish reliably between a radiculopathy and a peripheral nerve issue based solely on the clinical exam.   I have a general grasp of it already, but I want to be able to simply look at a bunch of exam findings, and remember them as a unit–the diagnosis they represent–rather than as individual pieces.   Which requires spending some quality time back down in the weeds of 1st and 2nd year, and integrating all of that with the hundreds of patients I’ve seen and will see in clinic with undifferentiated back pain, weakness or numbness.

I’m not a fan of the spine aspect of neurosurgery.  But if I have to learn it, I’m going to learn it like the back of my hand.

When I first moved here, I thought this place was going to be like the poor white trash cousin of its neighboring state, with which I’m fairly familiar.

But it turns out I’m wrong.  In fact, it’s a mystery to me why millions of people chose to live there instead of here.  This place is much prettier, and has a far more tolerable climate.  Not to mention better skiing within a reasonable driving distance.  As a city, it’s missing only a Chipotle.  Everything else is here.

Now, granted, the lack of a Chipotle (or its copycat, Qdoba) is a big void.  But I lived for two and some-odd years in New Orleans without one.  And I’m confident one will find its way here eventually (unlike NOLA with its distaste for non-local franchises, Starbucks in particular).

The city isn’t at its best this particular time of year.  But the department showed itself off well at its last interview day.  I was trying to view the day from the perspective of an applicant, and I have to admit, the morning conference was impressive.  And the ICU here is as nice as anything you’d find elsewhere.   Really, all it would take is one competitive applicant to be impressed and vocal about it, to put this place on the map.

A lot of random thoughts percolating through my mind today.   Because there’s lots of time to think at the VA.

Among them is, who in the hell called me from Seattle at 3am last night? That would be 2am in Seattle: the official drunk-dialing hour.  I didn’t recognize the number, though, so maybe it was just a misdial.

In other news, what I’ve been doing with all this spare time is reviewing all the crap I’ve forgotten since med school.  I found my old Moleskine notebooks, the ones I took notes in during all those lectures about various subjects in 3rd year.  So it’s kind of a jumble of topics, but each one distilled to its most essential points.

It’s also where I kept all of my ID’s, PINs, door codes and passwords from the multitude of hospitals I worked at during my clinical years.  I was shocked to realize just how many different places I’d been in those two years. In fact, I don’t think I was ever at the same hospital twice that entire time, with one lone exception: I did neurosurgery and ER/rads both at Ben Taub.

Seriously, here’s the list:

• Medicine at Charity and the VA
• ER/rads at Ben Taub
• Surgery at Hermann
• Neurosurgery at Ben Taub and M.D. Anderson
• Neurology at Methodist and St. Luke’s
• Psychiatry at Southeast Louisiana Hospital and Tulane’s student counseling center, and a home-visit outpatient psych service
• Pediatrics at Ochsner
• Away rotations x2
• Ambulatory Medicine at Tulane’s IM continuity clinics
• OB/GYN at Lakeview and Pineville
• Family Medicine at a clinic in the Marigny district

That’s a boatload of access codes.  And certainly nobody can dispute the breadth of exposure I’ve had to health care delivery in all its various forms.  However, it also meant a lot of chaos in my life during that time.  Constantly adjusting to new surroundings, new people and new systems takes its toll.

But the notes I took are surprisingly good.  Some of them I know I’ll never need, like the algorithm I wrote down for treating neonatal hypoglycemia.   But others I wish I’d had with me all along, like the one for evaluating acid/base disorders.  So I’ve been looking them over, and also searching the electronic resources currently available to me for other concise explanations, tables and algorithms that might be handy as well.

And now for something completely different.

It’s probably impossible to avoid all the hype going on right now about the latest movie installment of the Twilight series.  Although I have to confess, I would have been oblivious to the whole phenomenon had it not been for one of the female neurosurgery residents I met on the trail.  She noted that I was living in Seattle at the time, and asked me if I’d read the books.   She absolutely gushed over the first book, and when I looked at her blankly and said I’d never even heard of the series, she told me I must read it.

So I picked up a copy at the airport bookstore, and read it on the flight home.  The first book was equal parts fascinating and ridiculous.  Shallow enough that you could grasp it all on first reading, and certainly predictable with respect to the outcome, but with characters that managed to avoid banality nonetheless.  Silly in the extreme, but interesting.  And it had been a while since I had read anything that held my interest, so I got the rest of the series.  I didn’t like the second book, but the third one was good.  The fourth one nearly jumped the shark on multiple occasions, but if you could suspend your disbelief, it was a good story, and emotionally satisfying.

Sadly, they are not the kind of books that make good movies.  Too much of the story is in it’s characters’ heads, and it would require some serious acting skills to convey all of it with such limited dialogue.

My point, though, is that I’m not a snob when it comes to the books I like.  The hype and the obsession turn me off as much as the next person.  But if, like me, what you want is something entertaining and different, they’re a good read.

Well, I have a few more topics to discuss, but they’ll keep.

Well, one minor mystery solved.  I have this old Perkins loan from med school for which I never got one single bill or notice of delinquency from Tulane.  The first notice I ever got for this particular loan (and if you have as many as I do, it’s hard to keep track of them all.  In fact, I had made a point of keeping them all with one lender for that very reason.  But a Perkins loan is directly from the government, not through a third party lender, so I didn’t have that option.  And I’ll be honest, I completely forgot about it.) was from a collection agency who wanted to tack on an additional $10,000 to the amount owed.  This represents over a 50% fee on the original balance.  So I told Tulane I was willing to repay the loan to the school, along with any interest that had accrued, but no way in hell was I paying this usurious collection agency a single penny.

The school said it had sent bills, and I believe them.  But what had happened to them all?  Certainly I was getting all the med school’s requests to donate money.

Well, it turns out that the Financial Aid office for the main campus (not the med school) was sending the bills to Mystreet NW instead of Mystreet NE in Seattle.  And of course Seattle’s crappy postal service never figured it out, even though it surely is a very common error in a city where streets are named by quadrants.

And unlike the postal service here, which has managed to forward all of my mom’s packages to me, even though she addresses it to someplace 50 blocks away.

I was going to write this Thursday, but held off for reasons that don’t matter so much today.  Plus this past week contained the previously mentioned Bring Your Ativan to Work Day.  So it’s been altogether a very painful 5 days.

Nonetheless, I’ve decided that I really like Fellowship City.  I came to this conclusion Thursday afternoon as I was at lunch, staring at the snowglobe-esque scene outside the hospital.  I love snow.

I mean, I do like not having snow for a lot of the year.  But my family likes to live in places where it never snows, and this is yet another way in which I’m the black sheep.  So I was all excited about the mini-blizzard Thursday afternoon.  Particularly since it looked pretty and then melted before creating any rush-hour commuting drama.

Although the neurologists did cancel their grand rounds the following morning because of “inclement weather” (which by that time was sunny and well above freezing again.)  Wimps.

Also, I have a garage here, so there’s none of that annoying car window-scraping to be done when it gets below freezing.  Which makes all the difference. And the place where I go to swim in the morning (when I go) manages to keep the area around its semi-indoor pool warm enough to make walking from the building to the pool a realistic endeavor, even when it’s freezing outside.

So it’s an easy place to live, with respect to what I look for in a city.

I know there hasn’t been much talk on this blog lately about anything important.  But that’s because the drama around here right now is not about me.  And I don’t care to become an object of gossip, even if everyone does need something else to focus on.

OK, my neurosurgery peeps.  I know you want to know where to go in New Orleans.

Because you don’t want to go to Bourbon street.  Really.  It’s full of tourists and it smells like vomit. So here are some suggestions, courtesy of me (and people who are much cooler than me).

Food:

1. Port of Call
2. Franky and Johnny’s
3. La Crepe Nanou
4. Commander’s Palace (of course)
5. Brigtsen’s
6. Cafe Degas

Drinking/Hanging out:

1. Balcony Bar
2. Monkey Hill
3. Bulldog
4. Superior Grill
5. Dos Jefes Cigar Bar
6. F&M’s

Dancing/Music:

1. Tipitina’s
2. Maple Leaf
3. d.b.a.
4. Twi Ro PA

Coffeehouses:

1. CC’s on Magazine/Jefferson (my favorite place to study)
2. Rue de la Course
3. PJ’s
4. Cafe du Monde (have the beignets, or don’t bother going)

There are more.  You pretty much can’t go wrong anyplace on Magazine or Tchoupitoulas (“chop” in local parlance).

And last I heard, Joe’s next to Tulane Hospital no longer exists (sniff). Good old Lab J.  There’s some new hangout a couple streets over, now.  Handsome Willy’s, I think it’s called, but I remember it being more of an LSU med hangout than a Tulane one.  And I doubt it has an x-ray viewbox like Joe’s did.

Anyway, have fun, and laissez les bon temps roulez!

We had one of those deaths earlier this week that haunt you.  The kind where you keep going over everything that happened, wondering what it was that you missed, and whether there was something you could have done differently to change the outcome.  Because this was a patient who did not seem sick enough to die.

Hopefully we’ll get some answers from the autopsy.

And the fact that I see so much death that I can categorize it into “disturbing” and “non-disturbing” kinds, is itself a little disturbing.

It’s a rum and coke night tonight.  Except I’ve already drank as much as my puny tolerance will allow on a worknight.  Which was about a quarter of a shot.

I have this bottle of dark rum that I bought in Nicaragua (6 and a half years ago), and it’s hardly been touched.  In fact, it sat on my kitchen counter entirely untouched for 5 years.  And then came the Scramble last year.  After which it seemed a fitting time to break it open and have a glass.  I figure when people tell me to go have a drink, I’ve probably crossed over from the simply crappy to the truly craptastic, and a little lidocaine for the psyche is in order.

Today was one of those kinds of days.  Although now I’m just drinking plain diet coke again.

I’m not sure where to start with today’s events.  But I’m going to be a little more frank than usual.  I blame the alcohol.  It’s possible that I drank the alcohol in order to blame it, but nonetheless that’s my story and I’m sticking to it.

First of all, there were plenty of people around, but no one to whom I could actually delegate any real work.  We had an ER resident, who’s not allowed to consent anyone and can’t do any of the procedures that needed doing today.  We also had a new foreign medical grad, who also couldn’t do any of the things that needed to be done, couldn’t even write orders because she wasn’t in the system yet, and in addition to that kept asking me if there was anything she could do to help.  Which is twice as annoying when the person asking obviously can’t. We had one extra resident today, who showed up to run the list in the morning and then disappeared without doing any work.  This particular resident is a master at avoiding work and evading responsibility for it.  Although no one actually trusts anything this resident says, anyway.

I think that’s what bothers me most about this program.  The residents are not a team.  With a few notable exceptions, everyone is out for him- or herself.  No one has your back, not even the chief.  You would think that such difficult-to-please attendings as we have here would inspire a sense of camaraderie amongst the residents.  But it seems to do the opposite.

But getting back to today.  At about 1:30 I was trying to get some hemostasis on our new patient’s scalp wound when I got a spray of lidocaine, epinephrine and arterial blood right into my eye.  Body fluid exposures are frankly a pain in the ass, and I had too much to do to deal with one today.

But I’ve worked in health care nearly all of my life, and the two things that have been pounded into my head year after year are handwashing and the importance of reporting all accidents, mistakes and occupational exposures.  Plus, who can really be sure that this patient doesn’t have HIV or hepatitis? And it didn’t help that my eye actually hurt and I was developing a splitting headache.

And of course, just as I’m getting ready to head over to the Occupational Health clinic, I get a consult for an operative subdural in the ER.  Damn it.  I’m sitting there thinking, do I operate today, or do I get post-exposure prophylaxis and ensure that I can operate 10 years from now?  I wouldn’t be able to do both.  So I saw the consult, got the patient on their way to the OR, and headed over to Occupational Health.  No sooner was I back than one of the attendings sent some random person over to observe me do a neurological exam on a patient.  Then it was 4:30 and the chief wanted to run the list with everyone.  This took an hour, between rounding everyone up, updating the list, and then actually going through the patients.  No one was even consented yet for any of the procedures that needed to be done.  So I was in the middle of doing that when I got a call from one of the attendings asking me why the procedure hadn’t been done on their patient yet.

Well, not really asking.  More like demanding to know what I’d been doing, and telling me that what I had done instead was unacceptable.  Which, message-carrying ethos or not, is an indefensible statement coming from anyone in a position of authority in a hospital.  But it would have been counterproductive to point that out.  So I just quit talking, and instead listened quietly until the subject moved on to what ought to be done now to solve the problem.

The only good way I’ve found to deal with other people’s anger is just to let it flow around and past you like an ill wind.  It’s like walking out the door in Phoenix in the middle of summer.  All of a sudden there’s a burst of hot, dry, hellish air, and you just tolerate it for a little while until you get someplace air-conditioned again.  In fact, that’s exactly what I imagine in my mind’s eye as it happens.

Anyway, I ended up staying about three hours beyond signout in order to avoid dumping most of the work onto the on-call resident.

You know, the other thing this program needs is a more structured way of bringing people along from the knowledge level of a med student to that of a PGY-3.  They really haven’t had to do that with the vast majority of their residents, but it’s the kind of thing that programs who routinely match AMGs straight out of school obviously have to do, and seem to do well enough.

Then again, they use a lot of AANS materials here that I don’t have access to because I’m not officially a resident.  So maybe that’s where the teaching is.

Man, I thought some of the criticism I’m getting is harsh. –Not undeserved, let me make that clear.  Just very direct and with the bar always higher than wherever I am.  But I’ve never been told by anyone that I’m not cut out for neurosurgery. Lacking in knowledge and skills, yes.  But not fundamentally unsuited for the field.

Well, apparently, people do get told that.

Yesterday I put in my first solo EVD.  I know, I know, it’s freaking October, and this is my first?  WTF?

My sentiments exactly. Continue reading Shunt this, all you naysayers…

Yesterday, or maybe a couple of days ago–it all runs together when you take call three times in one seven day stretch, I had a rather long conversation with someone at work. Professionally, I like this guy, and personally we get along well. He’s also a very un-private person who talks freely about his life outside of work, so I know a lot more about him than he knows about me.

Well, the other day we were stuck together waiting for a patient to get scanned, and he started asking me all kinds of questions about myself. What I think of this program, whether I want to stay here, where I came from, why I’m interested in neurosurgery, do I have kids or a significant other, etc. Those of you who know me, know that when I talk to people, I tend to reflect their tone and level of openness in my own speech. So I pretty much told him exactly what I was thinking, which was not particularly wise or advantageous of me, politically. And socially it was entirely retarded of me, although at the time honesty seemed like the only respectable option.

But oh well, I guess at some point you have to let down your guard with people. Particularly when your job consumes as much of your life as neurosurgery does.

Go Margaret and Helen!  I just love those two old ladies and their liberal rants.  Then again, I just like old people in general.  They crack me up, because they say whatever the hell they want and really don’t give a shit whether you approve or not.  Which means that often times they say exactly what I’m thinking.

Except for my own parents, who drive me nuts with the exact same behavior.  The difference is that I feel like their behavior reflects on me somehow.  I worry that people think I’m secretly harboring the same opinions, because, you know, that’s the talk I heard at home.  And the reality is that my own values contrast pretty starkly with theirs in many ways.

Of course, the further away they get from the economically sheltered life of talented, intelligent and well-educated middle age adults, the less Republican their views become.  In contrast, there’s no explanation for my own political views, given that I’ve always led a fairly sheltered life in this respect.  I’ve just always been more aware of how easily it can all slip away in one random piece of bad luck, one random act of God, one natural disaster where you happened to be in the wrong place at the wrong time.

Certainly, there’s an element of individual control in all of these situations.  You can do like I did in New Orleans, and be aware what the risks are and pick a place to live that minimizes your risk of loss or harm.  But even so, your risk is significantly affected by other people choices as well, which you can’t control.  I didn’t have control of levee maintenance, or the city pumps.  I didn’t choose to try and piggyback Tulane’s entire medical curriculum on top of some other school’s very different educational philosophy and infrastructure.  I didn’t choose to bring the entire school back before there was a sufficient clinical volume and infrastructure to provide adequate clinical exposure and teaching.

But these are the kinds of decisions where the right choice is only evident in retrospect.  And what’s done is done. My point is that I’m acutely aware of the randomness inherent in life, and the whole point of having a safety net is that you never know when you’re going to need it.  And chances are that no matter how invincible and in control of your life you feel now, at some point you will fall.

This was brought home very starkly this past week, in which a resident in one of our programs sustained a severe brain injury.  He had done everything right, and still ended up in our ER with the kind of head injury that could have been fatal, or worse, nonfatal but neurologically devastating.  I had seen a similar thing happen at UW, although with a more severe injury and a different outcome.  That’s one of the hardest parts of neurosurgery: the knowledge that no matter what you do or don’t do, only occasionally are your patients totally normal again.

But that’s not the hardest part.  The hardest part is knowing that you made them worse off than they would have been without your intervention.  I mean, it sucks that we have basically the same number of patients as the general surgeons with only 1 resident in house compared to their 4, so it always feels like you’re being pulled in 5 directions at once.  And it sucks to have to explain in the morning why all 5 of those things didn’t get taken care of all at once like they needed to be.  But when you’re home and rested, it’s the people you harmed that haunt you.

Not that I have a lot of experience with that as yet.  Mostly it’s vicarious, when I examine somebody that has a new deficit that wasn’t there prior to the surgery.  But the attendings mentally flagellate themselves whenever it happens, and you can see it in their eyes.  Often times, they’ve done absolutely nothing wrong, and this is just that 1 in however many cases in which this adverse event occurs.  But for that one patient, it doesn’t matter how low the odds were.  Nor is it their fault, yet they have to live with the consequences.

So how you can be a Republican, and against truly universal health coverage, as well as other social safety nets, when every day you see before you evidence that we’re all just a heartbeat away from the kind of loss that lands you on welfare or disability for the rest of your life, is a mystery to me.

Today was a bad day, for reasons that will probably seem a little ridiculous/arrogant/spoiled/some combination thereof.  I’m pissed off with myself today because two of my patients were worse off this morning than they were yesterday.

This kind of thing does not happen to me.  My patients who should get better, do.  And those who get worse or die do so because either we can’t save them no matter what we do, or we’ve chosen patient comfort as the treatment goal, rather than palliation or cure.

It’s those damn lungs again.  When patients start having pulmonary issues, some part of my brain goes, “Ack! Physics!” and just shuts down.  Which is silly, because I have a decent intuitive grasp of the processes involved, and am certainly capable of figuring out what’s going on.  I just, for whatever reason, feel intimidated by pulmonary issues, and therefore have a tendency to stand back and let other people solve that particular part of the patient’s critical care management.  And the end result is that I’m not very good at sorting out ICU patients once their lungs start causing problems.

This must stop.

As an intern, I was one of the ones whose patients rarely did poorly, and I like to think that it was because I was on top of their care.  I knew how to keep a small problem from becoming a big one, and could tell when something looked bad but didn’t mean anything.  And also, equally important, when something that seemed small and insignificant was actually an early warning sign of decompensation somewhere.

I do not have that level of clinical insight yet with critical care patients.  So I don’t know when to push back on a plan that I’m not sure is correct.  I don’t know at what point to call and say: the plan is not working, we need to reassess.  Nor is it even clear to me sometimes exactly what part of the plan is not working and needs reassessment.

Part of the problem is that some attendings’ plans seem to work better and more consistently than others.  And I can’t quite put my finger on why that is.  All I know is that with some attendings, patients always get better, the plan is clear and either I understand what’s going on and how to deal with it, or there is clearly a new problem.  With other attendings I end rounds more confused and fragmented in my thinking than when I began.

But really, that’s no different than when I was an intern dealing with various chief residents.  However, toward the end of intern year, I knew what I was doing, and so I relied far less on my chiefs for direction.  Plus I knew how to manage the people above me in order to avoid getting a poor plan for the problem in question. (Anyone who says that you don’t manage your chiefs and attendings is either clueless or lying.)  I’m gradually learning to do that here, but it’s one of a great many things I’m trying to learn at once.  And it’s not an excuse.

So I’ll just have to keep reading and trying to understand, and make a more dedicated effort to master pulmonary critical care.

This has been the strangest couple of weeks ever. First of all, last week I was assigned to clinic for nearly the entire week.

That’s why people go into surgery, you know.  For the clinic.   Continue reading How long before I begin, before it starts, before I get in?…

Back in college, my friends and I had a saying: it’s not what you do, it’s who you follow.  Meaning that evaluations of how well you did your job are relative, and the key to looking like a star is to follow after someone who screwed up royally.  And that if you have the bad luck to follow someone outstanding, it’s nearly impossible to look anything but mediocre.

The phenomenon isn’t obvious until you spend several years observing an organization with semesterly turnover of 30+ leadership positions, all of whom are people you know well and have worked with in numerous capacities.  But once you have, it’s hard to miss.   And frankly, I’ve never had an evaluation that wasn’t strongly influenced by where the person ahead of me set the bar.  Not that that’s all there is to it, but it’s a far larger component than people seem to realize.

That’s all for today.  I have reading to do.

I’m not an active part of this policy debate, but here’s my take on health care reform. Continue reading My two cents…

Apparently I’m not TOO sleep-deprived at the moment, since I was up in time to go to work this morning, and I’m off today.

The hospital claims they will be fully implementing Cerner in a month or two.  Everything all at once, including physician order entry.  This should be interesting.   Continue reading Coming soon: bring your ativan to work day…

I get a sense from the residents here that they’d consider it unfair if the place I just interviewed at offered me a spot.  No one’s said anything overtly, but there’s the unspoken question hanging in the air, “why you? what makes you so special?”

And it certainly wouldn’t be fair.  Then again, “fair” presumes that the playing field is level.  But there’s nothing fair about whether or not we’re given an opportunity in life, there is only what we make of the opportunities we’re given, and what that says about us.  And I know I’d make the most of that opportunity, and that it wouldn’t be wasted on me.

There’s a whole crapload of “unfair” I’ve been dealt in my life, and wouldn’t it be great if I really could build that metaphorical skyscraper of a career that I talked about so many years ago, despite it all.

As you might expect, being a PGY-2 in all but name leaves very little time for blogging.  Also there may be some really good news on the horizon (at least, I hope so!), and I’m just superstitious enough not to want to jinx it by talking about it.  Irrational, I know, but there you have it.

My main impression so far is that neurosurgery here is harder than it needs to be.  It’s true that at this place, you have to know your medicine and general surgery cold, as well as neurosurgery, and that’s certainly challenging. But they round for half the day here, which leaves very little time for actually getting any work done.  I have mixed feelings on this subject, mostly because, while I recognize the need for oversight, it feels very haphazard and inefficient as a means of teaching about critical care, not to mention neurosurgery.  I don’t feel like I’m learning much, other than that everyone has a different way of doing the same thing, and that good clinical judgment is a thing totally separate from being conversant with the literature of the field.  There are many things done here that are no longer done elsewhere, and things done routinely elsewhere that earn me that “Are you f-ing crazy?” look here from staff and residents alike.  And something tells me that being taught anything by someone in my position would be counterproductive as far as my intermediate-term goals are concerned.  In other words, while my long-term goal is to become an excellent neurosurgeon, I can’t be excellent at it if no one will let me do it in the first place. Which requires a residency, and pissing people off is not the way to get one.

However, the pharmacists here are on top of their game, and would give their colleagues at Harborview a run for their money.  They don’t round with us, but some of the protocols they have in place are well ahead of trends in the field, and they pretty much get what they want.  But the pharmacy practice act in this state is clinically the strongest in the nation, so that’s not surprising.