Hurricane Jill

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.

Posting from my interview at Gigantic Hospital.  I’m still mystified as to why they’ve invited me to interview.  I must be their token outside applicant.   I hope not, though, because this interview is costing me a fortune. 

There is apparently no way to do this cheaply.  My lone cost savings was on the plane ticket, for which I spent a large portion of the miles I had accumulated from last interview season in order to avoid paying actual cash.  I was saving them for a rainy day, and well, it’s raining.

Anyway, this place is everything I’m looking for in a program.  I just hope I’m what they’re looking for in an applicant.

Another call night, another incremental gain in knowledge.  This time I can tell that there’s a difference.  Maybe no one else can, just yet.  But I know that two weeks ago, this past night would have had me rending garments and comtemplating the consequences of skulking away at 3am and never coming back.  (And before you pass judgment, we have a census that would support at least one additional resident every other year than the program currently is allowed.  Plus we are the critical care service for the neuro ICU, including the neurology patients, in addition to handling neurosurgical issues.  I like this, and I’m not complaining.  But it is more work, and more stuff for me to learn.)

But somehow it wasn’t that bad.  There were consults, there was power-paging by what seemed like the entire hospital while I was gowned and sterile for a line placement, and thus unable to answer.  And during which I was also completely abandoned by the patient’s nurse for at least 20 minutes.  Which is a fairly serious no-no of nursing, if I understand correctly.  That nurse was obviously hating her life last night, as she was saddled with two brand new, unstable patients, both of which needed tubes and lines and labs and scans galore.

And yet, all of those things got done.  Not quickly enough to make my senior happy with my work, but whatever.  There are some situations where you’re just never going to win, and it’s important to know when you’re in one.

There were a few things that didn’t get done, but then again, it’s not like I slept at all, or even ate a decent meal.  In fact, I’d been there 18 hours before I’d even had a chance to go to the bathroom.  And I’d had to go since that morning.

I’m waiting for the day when we ask some patient to ” show me two fingers!” and the patient flips us off with both hands.  It’s gonna happen someday, I just know it.

Anyway, I have one dictation left to do from today.  And unfortunately, I’ve just discovered that the hospital’s dictation system doesn’t recognize the keypad touch tones from my iPhone.  And I don’t have a landline, so I’m basically screwed until tomorrow morning.   But hey, there’s only one this time.

And most importantly, no one died last night.  In fact, nearly everyone is doing better this morning than they were yesterday.  And nobody chewed me out for any of the changes I made overnight (although this is partly because I’m overcautious now.)  But equally important, no one got mad at me for not making a change when one was needed, or not discussing it with someone senior to me.

I’m starting to think I might actually get the hang of this at some point.

It’s been a long couple of weeks.  Longer because I stayed far later than normal a couple of times in order to learn some new things.  Like invasive line placement, a skill at which my lack of experience was apparently quite unexpected.  UW doesn’t give its interns much opportunity to place central lines or arterial lines.  But as it turns out, it’s not actually that difficult.

I’m not keeping very close track of my overall hours, since it really doesn’t matter.  But I think the schedule I’m on involves alternating 100- and 60-hour weeks.   Which isn’t bad, compared to what my schedule might have been like elsewhere.

Right now, I’ve got several very irksome problems:

1. It’s been over a year since I worked as a physician, and the mindset is completely different from that of a pharmacist.  Granted, it’s a better fit than pharmacy, but there’s still an adjustment to be made.  Another aspect of this is my habitual use of weasel words.  I got in all kinds of trouble in pharmacy school for making definite statements in response to drug-related questions.  And I remain persuaded that few things in medicine (or surgery) are truly black-and-white.  But there’s no Heisenberg principle in surgery.  Either it’s operative, or it isn’t.  And either you operated, or you didn’t.  There’s no shadow world where it may be either case in the future, or could be both at once.  So the weasel words have to go.
2. There’s also a huge difference between being a trainee and being a fully independent professional, legally responsible and expected to make my own decisions.  I’ve spent the last year making my own decisions, answerable only to my own conscience and a court of law.   It’s hard to regain the balance I had finally struck as an intern, between knowing when to simply do something I knew was correct, and knowing when to ask permission anyway.  So right now I’m getting very mixed messages on how I’m supposed to behave: I don’t run things past my seniors enough AND I’m not independent enough.
3. On top of this, there’s a lot of stuff I flat out still need to learn.
4. There’s also a lot of stuff I know, but can’t recall with enough facility at the moment due to the stress of all these other things I’m trying to get right.

So, you know, the going is a bit tough right now.  And there are some days when I understand why residents quit or transfer into other fields with such frequency.  It’s hard to face seven years of feeling like an idiot about some thing or other every day.  Much easier to break it up into smaller pieces, like a medicine residency and fellowship, where at least in the middle you get to feel like an almost-attending.

But I’m not going to be one of those people.  For one, I have an abnormally well-developed tolerance for delayed gratification.  And secondly, I can’t really picture myself doing anything else.  At least, nothing else that doesn’t require a residency that would make me go postal (integrated vascular spots are too scarce to be a realistic option).

And don’t even talk to me about ENT.  Blood, guts, vomit, stool, smushed brain: none of those bother me much.  Earwax, however, nauseates me to the point where I have to put the scope down and leave the room.  It makes no sense, but we all have our kryptonite, and that’s mine.

I’ve learned a lot already, in just three weeks.  And now I have this weekend free to do some actual book-learning.  Hopefully it’ll make the next two-week sprint a little less painful to my ego.

I survived my first call.   There was one death on the service, an assault victim-turned-homicide for whom there was nothing we could have done.  And one ICU transfer that I’m not entirely sure was inevitable.  As far as I can tell, the rest of the patients were not worse off in the morning for the decisions I’d made overnight, although there were a couple of instances where I wasn’t able to defend myself adequately when put on the spot, though that doesn’t necessarily mean I was wrong.  The number of consults was about what you’d see on a light night in Seattle, but the process is far less streamlined here, so it seemed like a lot more work.  In fact, pretty much everything here seems take a lot more effort to get an acceptable result.

And then list is pretty long right now, which meant that there was a lot of work aside from the consults, and there were a couple of things that didn’t get done.  Which is never a happy thing to have to report in the morning.

And now I need to come up with a research project.  I was hoping that I’d be inspired by some case that came in while I was on call.  But frankly, the question that kept popping up in my head was, how many days is one’s life shortened by each overnight call?  Does it age you an extra week or so?  Or does it just feel like it ages you excessively, without actually doing so?

By far, though, the biggest surprise was how much energy I still had the next day.  I didn’t sleep, and yet physically I could have gone at least another full day.  Mentally, probably not.  But that has more to do with where I am on the learning curve with all this stuff than anything else.  In time, there’ll be fewer things I have to think my way through from scratch, and I’ll become physically exhausted well before I run out of gas mentally.

As an aside, that’s why I think hour limitations aren’t such a bad thing overall for interns, and why I don’t think they work as well for senior residents and chiefs.  People don’t usually make mistakes because of physical exhaustion.  They do so because they’re mentally exhausted.

I read recently that when asked how he would spend an hour, if that was all he had in which to come up with a way to save the world, Einstein said he would spend 55 minutes formulating the problem into a question, and only 5 minutes answering it.

Perhaps if we made that distinction between mental and physical exhaustion in our discussion of work hours vs learning vs patient safety, we might come up with better and more workable solutions for all aspects of the problem.

Wow, a year away from surgery has done bad things to my stamina.  More mentally than physically, but both still need work.  Yesterday was only a twelve hour day, and yet by the end I could hardly think straight.  I’ll have to build it back up again, and quickly.

It was partly my sleep schedule, which had gotten way off kilter such that I woke up at 1am and couldn’t get back to sleep.  But even so, I shouldn’t have been that tired.  I think the real problem is that my cat thinks I’m a large toy when I’m asleep, and likes to pounce on my face and torso, claws extended, at random times throughout the night.  Which isn’t great for sleep quality.

I may have to kick her out of the room at night.  Or have her declawed so that I don’t have to be so hypervigilant about an accidental claw to the eye while I’m sleeping.  Declawing is probably the more humane option in this particular situation.  But God, from the reaction of the shelter people to the idea of declawing, it’s like you’re threatening to murder small children.  I mean, come on!  What’s crueler in the end, nightly isolation from her human in addition to all the hours I’m away in the day, or a one-time procedure under anesthesia to amputate the front claws of an entirely indoor cat?

Yes, I said amputate.  I know you people use the word as an emotional appeal, to evoke images of a barbaric and painful procedure.  But I’m a surgeon; I know exactly what it involves, and it’s no more barbaric than spaying when done correctly under anesthesia.  And make no mistake, we spay and neuter primarily for our benefit, to control the number of cats who become feral, and ensure that the population doesn’t exceed our ability to care for them.

Declawing is no different, in that it enables me to give her a better quality of life without jeopardizing my health and safety.  In any event, I don’t see a better solution at this time.

(Note: Actual cat juggling is wrong.  Also not funny, unlike Steve Martin’s stand up routine about it.)

Orientation is a necessary evil, I guess.  But really, how many times do I need a review of OSHA regulations and handwashing?  Or HIPAA?  Well, I’ll admit I haven’t had quite as many reviews of HIPAA.  But my training on its bastard cousin HIPPA has been so frequent that I now despair even about graduate and professional education here in the U.S.

So I entertained myself yesterday with a comparison of how different institutions emphasize different things in their orientations.   Where I was before, their main goal was to get everyone ready to work on Day 1.  So we got set up with pagers and chart access, scrubs and labcoats, door codes, dictation codes and cheat sheets, and lots of talks about what to expect on the service, professionalism, etc.

Here we did bloodborne pathogen training, basic network access but not chart access, nametags, insurance cards, work/life balance, ACGME competencies, the standard HIPAA {“HIPPA”} presentation, and had a discussion of appropriate prescribing practices.  But nothing in terms of getting what we need to do the actual work of a physician.  No chart access, no scrubs, no lab coat, no pager.

Fortunately I had some free time in the afternoon while everyone else was off getting oriented at a hospital where I won’t be rotating.  So I got all of that done.  But had that not been the case, I would have been woefully unprepared to work today.

The date for the post “Not a moment too soon” has been changed to June 8. Apparently delayed publication on WordPress works differently than it does on Blogger.   On the old site, when you saved a post and published it later, the date remained that on which the post was created.  Which I like, as it gives a better sense of continuity for the overall narrative of this blog.

Apparently WordPress changes it to the date you decide to publish it.  Which I don’t like.  Future delayed posts will be dated according to when they were created.

Those of you with PhDs, or who have friends with PhDs, will enjoy this site.

So, the agenda for today: lots and lots of reading.  On the chairman’s recommendation, I’m skipping all the watered down neurosurgical texts and diving right into that 5000-plus page behemoth known as Youmans Neurological Surgery.  And ominously, the first thing that struck me about it was the brevity and precision of the writing. Continue reading Cyberstalking…

Of course.

The week before I’m scheduled to start here, not one, but two(!) actual PGY-2 residency spots pop up on my radar.

I knew this was all going far too smoothly to be the whole story.  Well, no matter. For at least one of the two, I’m sure there are plenty of PGY2’s currently in residency already who would jump ship at a moment’s notice to transfer there.  And the other was posted much more visibly, which means they should get plenty of applications as well.

As for me, I’m not really sure what’s the right thing to do.  I like it here, but what kind of person passes up an actual residency position to be a pre-clinical fellow?  Either someone not very smart, or not very serious about becoming a neurosurgeon.

Today’s post will be a grab-bag of random thoughts.

First of all, my kitten is clearly in the middle of the Terrible Twos.  Everything is a toy.  All food is cat food.  Playtime is 10pm to 6am.  Chomping on human body parts is a sign of love.  And apparently things that are Not OK and she gets sprayed with water for at one point, might suddenly become OK at some later point.

Despite that, she is obviously a smart cat.  I bought this toy for her that consists of a pole with a piece of string tied to it, and at the other end of the string is tied a feathery-thing.  When I first got her, she would play with the feathery thing.  But then one day I saw her look at the feathery thing, notice that it was attached to a string and visually follow the string back to the pole, and the pole back to my hand.  And now my hand is the toy.  Time for plan B.

Another thing that’s bugging me:  where the hell is the outgoing mail box?  I’ve looked everywhere, and I can’t find it.  The welcome packet has useful information about everything else, like where the switch is that coverts the bath to a shower, where my breaker box is, what I can recycle and when trash day is.  But about outgoing mail?  Nada.

So I just put my outgoing mail in my incoming mailbox, with the stamps on the side where you can see them once you open the box.  Hopefully the mailman will either pick them up, or take pity on me and leave some instructions on how to send mail from here.

Courtesy of a friend via Facebook:

Cakewrecks!

Good for an old-fashioned laugh-until-you-cry-and/or-can’t breathe-anymore session.  Although you do have to get past the Michael Jackson tribute before it gets truly funny.

As you may have gathered, I’m trying to avoid giving away too much information about my location these days.  My reasons are entirely selfish. Continue reading 9 days…

Well, as you can tell from this post, my computer is back up and running. Which also means that the Desk From Hell has been successfully reassembled. Continue reading Fellowship City…