Surgery Grand Rounds

 

General surgery M&M and grand rounds conference has been more formulaic than the average medical service grand rounds.  It always starts in the same way.  A resident goes forward to present on a patient who was very sick or died that month (morbidity and mortality for those of you not in the medical field, an M&M unfortunately completely unrelated to chocolate), and the attendings decide to talk about everything that is wrong in medicine in the seemingly impossible aspiration that it will lead to "quality improvement."  But since medicine tends to be practiced in the same way week after week, the conference tends to become repetitive.  Here are ten gems to bring up if you ever happen to be an attending at a surgery "quality improvement conference."

1. Excuse me resident, did you happen to do a (insert atypical diagnostic test) before you did (insert standard diagnostic test)?
   
2. Did you do a rectal exam?
   
3. Wait go back (insists on going back to first slide that states only age, gender, and chief complaint), what is the prognosis?
   
4. Did you do a rectal exam?  I don't think our residents are giving everybody rectal exams.
   
5. Resident, have you read any studies during your research that explored (insert any question, related or unrelated to case)?
6. Did you do a pelvic exam?
7. Wait, could you go back and explain (insert exceedingly basic medical knowledge) for the medical students?
8. Did you do a rectal exam?  I would like to emphasize the importance of rectal exams.
9. (Question resident in audience) Let's make sure we're paying attention and learning, what are the approaches for the procedure? (word this question as bizarre as you can so that you can correct the resident when they are done speaking)
10. I would just like to comment that the rectal exam is very important.  

--By Farrah, who would like the reiterate the importance of rectal exams.  Oh yeah, and shout out to Amar who was sitting next to me in grand rounds while I was drawing the picture.  

Musings while on Surgery Call

I imagine that when you used to tell people you were in medical school in the olden days (i.e. the 90s), they would think "NERD" or "GEEK" or something decidedly low on the social ladder. In the'00s because of popular primetime dramas like Grey's Anatomy, medical school is one's path to a life of nonstop glamor and sexual hijinks with fellow residents. For instance, the "on-call

My On-call room. Notice the Coke. A call must!

room" has a whole new connotation since the crazy cast of Grey's has popularized it with extra-curricular activities other than sleeping.

But here I am, nearing the end of my third year of medical school, and I can definitively say that while there may be some eye flirting between MS3s (the equivalent of "fresh-meat" in college) and the tired residents, life as a student is just one large charade of pretending to be a doctor. Here are some examples:

Seemingly Glamorous Activity: I'm on 24-hour call tonight, and when I tell non-doctors this fact, they are probably thinking, "Wow impressive! Saturday call - you must be really committed to be a doctor to sacrifice weekends." People might wonder what kinds of fun things I do when there is a trauma emergency - as I run in scrubs that fit me perfectly to the ER.
Reality: I've been sitting in a windowless call room with no cell phone reception for over 12 hours. No one has paged me to do anything, and my afternoon has been spent studying and watching a documentary on Roman Polanski (he was unfairly convicted!) and Little Mosque on the Prairie episodes. If there is a trauma, I'll most likely walk at a brisk pace to the ER and then act as an extra as real doctors run the show.

Seemingly Glamorous Activity: Pre-rounding on patients at 6 AM and writing notes about their progress overnight. Improving patient care, saving lives, and taking names.
Reality: I write progress notes that I can't put in the medical chart or the attending physician will get sued. No one ever reads them so my elaborate works of progress note art are relegated to my pocket. The question remains: if a SOAP note is written in the forest, and no one reads it or acknowledges it, does it even exist?

Seemingly Glamorous Activity: Scrubbing into a radical neck dissection surgery in the OR. This is preceded by going through the entire procedure of scrubbing and possibly flirting with cute resident/student by the metal sinks while soaping up one's arms into a heavy lather.
Reality: Scrubbing in for a student means holding a retractor at an awkward position for hours on end. The uncomfortable angle makes me wish that I could cut my arm off just to end the misery. And unless I want to stare longingly into the eyes of the middle-aged scrub nurse, mother of 5, then it's best to look straight ahead into the sterile field.

And so, while rotations are a necessary part of preparing us for the responsibilities and hardship of residency, the tediousness sometimes makes me wish I were an intern already, despite the low pay and lengthy hours. After one year of this, I'm ready to stop playing doctor, and actually, you know, be one.

--By Mariam, who hopes that no one gets drunk and hits their head or gets run over by a car tonight (i.e. the bulk of traumas at the UT ER).

UNC: 2009 NCAA Champions

Naadia and I ventured off to Motown City to attend the Final Four last week. Sure, it cost us an arm and a leg for tickets. Sure, we were in virtual nosebleed territory despite sacrificing aforementioned arm and leg because of the shitty seating system at Ford Field. Sure, half of the crowd cleared out 1/4 of the way through the Villanova-NC Final Four game. And sure, we were surrounded by a literal sea of Spartan forest green. And no problem, that we were late to both games due to technical difficulties beyond our control. And, sure we got lost both days because I-75 S to Toledo was closed and we had to take a scary detour for almost 30 miles before we got on the right track. And finally, no problem that when NC won rather anti-climactically in the final game Monday night, the Michigan State fans cleared out like someone had yelled "fire" in a crowded theater, and no matter that there were about 200 people left to celebrate the glorious Tarheel victory. And also no big deal that the next day during surgery lecture I was so tired that I hallucinated that the professor was talking about going to Costco to buy normal saline when in fact, he was talking about cholecystectomies.

In the end, despite all of these factors and the subzero Detroit tempeartures in APRIL (April is the cruelest month when you live in the Siberain terrain of the mid-West), it was still worth it to see Tyler Hansborough and friends single-handedly crush the dreams of an entire city on its last legs as it is mired in an economic depression and soaring unemployment rates. It was still nice to see Goliath take home the glory for my home state of North Carolina. Because even though we always love an underdog to come home with the prize - a la Ralph Macchio at the end of The Karate Kid - it so rarely happens in real life. Because hell, Goliath is an unstoppable machine with at least 6 future NBA players. Eat it, Detroit.

--By Mariam, who thinks that she should have gotten AP credit for the surgery rotation since it literally has taken the life force out of her.

Cosmo confession: I was a TV Extra

We all do embarrassing shit when we're younger. We wear hideous clothes like tie-dyed T-shirts or Hard Rock Orlando sweatshirts. We may get high on caffeine pills and accost our Upper School director. Or we may have had a profound love of Boys II Men. But there comes an age when your misguided thoughts on what seemed like a good idea are actually just unforgivable.

For instance, when I was a junior in college, my friend Bushra and I decided to be extras on the teen drama One Tree Hill. We got the call from a casting company asking us if we'd like to be extras, and I thought, "OMG OMG OMG CHAD MICHAEL MURRAY IS A HOTTIE!!!EEEEEEEEEEEEKKKKKKK. THE SHOW IS SOOOOOO AWESOME.!?!" in the manner of a teen girl with the latest copy of Tiger Beat. And so, we took the day off from our classes and drove down to Wilmington, NC (known as Wilmywood by locals) to participate as glorious extras and get paid a tremendous sum of $60 for 14 hours.

I am not sure how I imagined my stint in show business - maybe some glamour and fraternization with the talent. I rehearsed what I'd say to Chad, "Hey, I think you were so great on Gilmore Girls! Want to chillax later?" Maybe one of the actresses would like my top and ask me where I got it, and I'd tell her with an air of sophisticated casualness.

What I imagined in my mind's eye was far from reality. When we got to the designated meeting spot, the extras from all walks of life (mainly unemployed townies and trashy bottled blonds from the local high school) were ushered into yellow school buses like cattle. Inside makeshift tents, the production assistants told us to keep quiet and not to ever talk to the talent. We were lowly human beings or "background artists," not worthy to be spoken to by superior Hollywood folk. If we did dare talk to the actors, then we'd be banished from the set, never to work in the "biz" as background artists again.

Our assignment was simple. Walk back and forth in a club scene. Bushra, sensing her inner hotness, whispered urgently to me, "Mariam, they are picking cute girls to dance in this 'club' scene, and that's haram, let's move to the back so we can lay low."
Never one to rock the Islamic boat, I hid behind some tall African American guys. And so, we merely walked back and forth, mouthing to each other, even though we were not in the shot. I stared at Chad Michael and all of the other D-list actors with great awe, and I thought, someday I'll be back, but I'll be a part of the crew! And as you blog readers can see, that wish certainly didn't come true, because here I am, in medical school and not in Hollywood (or even Wilmywood).

Anyway, Bushra started to sense the low-class nature of extra work and started to get agitated.
"Let's go! This is so lame!" she whispered.
"We can't! We'll ruin the continuity of the episode!" I said, ever the ye old faithful to Hollywood magic.
"This whole scene is so trashy" Bushra countered. She was my means of transportation so I finally acquiesced begrudgingly. I had realized early on the trailer-trash nature of the whole activity, but I didn't care - so caught up was I in learning the anatomy of making a TV show. We grabbed our stuff and I sadly made a run for the parking lot, fearing that the One Tree Hill crew would hunt us down and make us return to the "club."

And that was the day I gave up hope of working in Hollywood. I should probably thank Bushra for crushing my dreams like a cockroach on the wall, but I realize what could have been: I may have ended up a washed-up, 40 year-old extra in Wilmington, hanging out at the local casting office, begging to be cast in a high school classroom scene or the big prom episode. Instead, I sit back hundreds of miles away from Wilmywood and watch Chad Michael Murray's shitty acting chops on my 42" TV. Ah, the life.

--By Mariam, who is loving OB/GYN!

Specialty Scoreboard

I'm done with almost 75% of my medical school education now.  It's hard to believe, and I hope that somewhere in this chaos I learned something.  I don't know if I'm wiser, but I really do feel older, like George W. after 4 years in the white house, extreme stress brings out your mature look.  I went into medical school with an optimistic vision of me as an OB/GYN, maybe coming to the aid of the lady who went into labor at grocery store, or TJ Maxx.  I'm not so sure OB/GYN is my first choice after three years of school, but here's the current scoreboard of specialties I've already done with arbitrary numbers assigned to each specialty.  

Internal Medicine: 57.43 points

Hospital: Can you say diabetes medicine management? Most interesting things were consulted out to infectious disease, cardiology, nephrology, pulmonolgy, etc. and all that was left for the primary, trampled on internal medicine team was making sure Mr. Jones didn't go hypoglycemic in the middle of the night.  To be fair, this was probably where I learned the most about the kind of medicine you see on the average medical board exam.

BONUS! Internal Medicine Outpatient: negative 1,000,000 points

Seriously one of the most boring times of my entire life.  And the patients were mean, and angry, and yelled at me, and stupid, and ugly.  Learned an awful lot about how NOT to do a physical exam properly.

Nephrology: 77.777777 points

Nephrology gets more points because it was slightly more interesting than internal. When you can focus more on a single subject, you can really start to understand it.  Still there is a lot of poorly managed diabetes around, and the strain dialysis takes on the patient's life is hard to watch.  The thought of having to endure an internal medicine residency to get to the nephrology fellowship is too much to bear. 

Family Medicine: negative 3,234,782 points

I am NEVER NEVER NEVER NEVER NEVER going to do Family Medicine.  There are a lot of people who feel comfortable tackling a little bit of every specialty.  I am not one of them.  I encountered a few family doctors who were really good at combining everything, but I also saw quite a few bad docs.  I encountered a doctor tell a patient that she should absolutely not get Gardasil - that's not informing the patient, it's forcing your opinion on the patient.  

Pediatrics: 53,234,598,371 points

I loved pediatrics.  It's lighthearted and fun because it has to be for all the kids right before you shoot them with a vaccine!  Most people who don't like peds cite dealing with the parents as the biggest deterrent, but I love that parents bring their kids to the pediatrician - when else will you get patients who so actively seek health care and follow up.  Even the parents that don't take good care of their kids, I would love to be the doctor that is the advocate for those children.  Plus I dearly love to laugh, and 3 year olds are hilarious.  Just note the following conversations:

Me: What do you want for Christmas?

Kid: um... A SHARK!

Me: What do you want for Christmas?

Kid: well... um... PINK!

Me: Are you sure? Just pink?

Kid: I guess... purple?

*Kid who has recently eaten blue popsicle*

Me: Oh my, your tongue looks like a smurf!

Kid: uh...

Me: Do you know what a smurf is?

Kid: nope

 

Psychiatry: 15.005 points

Psychiatry gets a lot of lifestyle points - the hours are truly awesome.  Short days, home calls, and no blood.  However, I really dislike working with the angriest people in society.  After a patient told my fellow med student Steve that he could stab Steve in the neck with a ball point pen if he felt like it, and that he could slap the hell out of me, I wanted OUT of psych.  6 weeks was plenty for my lifetime, maybe I'll do a child psych rotation, but that's it.  

OB/GYN: 799.99 points

I got really lucky with my OB/GYN rotation to get the private practice office with basically the best hours an OB/GYN could hope for with only 4 calls per month, and normal office hours otherwise with no weekends.  I really like my attending, and I don't think childbirth is as gross as others had described.  I also really like the patients, and interacting with them.  However, the estrogen impact is overwhelming at times.  There are only women in the office, and women in the patient rooms, and no doubt more women floating in-utero waiting to be born.  It's a lot like that movie The Women starring all women, that I do not recommend unless you are really in touch with your feminist side. All that estrogen left me with chocolate cravings and spontaneous crying for the first 2 weeks of the rotation.  I also had the inclination that I should start moving more aggressively towards having a baby of my own.  Woman were coming in at my age, well off and happily married for several years, having their second child - people with family first, career second - it's practically unheard of among the female medical student!  Things have eased up a bit now that I'm on week 4, but I'm still a little wary of the specialty when I see signs in the office that say things like "If you have melted chocolate on your hands, you are eating it too slowly!" or "OB doctors help to bring a little more sunshine into this world."  It's okay to cringe, I did.

Surgery: ??? points

Surgery is my next rotation, so we'll see.  My tallest friend asked me, "Will surgery be like baseball?  Fun to play, but really boring to watch?"  I think he's probably right, and I'm in for a boring few months.  Hopefully I'll get to do a few things and find out if I actually like it.  I like watching baseball at the stadium, so maybe surgery will be more exciting live.  

--By Farrah, who wonders if she should be studying right now at this very moment

Those Cute Slumdog Kids

I will wholeheartedly admit that I loved a mainstream movie - a film for the whole family, one even my 12 year-old cousin in Pakistan loved - Slumdog Millionaire. The kids in the movie were adorable - with their wide, sad eyes and grubby faces and their precocious acting. The movie had a real-life dimension, too, as the child actors, who lived in Garib Nagir in Mumbai (which literally means Poor Corner), got to attend the Oscars a few weeks ago. The two youngest kids looked so excited even though they probably had no idea who Kate Winslet or Mickey Rourke were. In one interview with the E! Channel, Ryan Seacrest asked one of the little kids how he liked working on the film. He looked at him in a puzzled manner the way my grandma used to look when a white person spoke to her. Then the other kids piped up excitedly, "He doesn't speak English." Watch the video of crazy Oscar hijinks below:



This moment reminded me of my own childhood because for the first few years of my life I only knew how to speak Urdu. Here I was, a little foreign FOB preschooler despite having been born in the whitest area of America - the Midwest.

When I got to preschool, my parents did not seem to be concerned that they were sending their FOB-ish 4-year old, who did not have a basic grasp of the English language, into the proverbial lion's den of little white kids, who could attack the foreigner in their midst at any time (this was the South after all, with its dark history of the KKK and lynching mobs). However, once I got to preschool, there were only minor kerfuffles with the whole language barrier thing. I remember getting Urdu and English words confused a lot, and I would tell my teacher about "anecks" (eyeglasses in Urdu). She would look at me in confusion and probably thought I was a kid with neologia.

Now, since I lived in the country with no siblings, I also developed a selective FOB accent. Once in kindergarten, I told Mrs. Caldwell about how my dad went to the "e-mur-gen-cy room" for his job, and I ate "veg-e-tables" at home. She looked at me with a casual disdain and said haughtily, "It's ee-mur-gency and -veg-table!" That day I promptly went home and told my parents that they pronounced these words incorrectly. And so, we sat in the car together and worked on our pronunciation chanting, "ee-mur-gency" and "veg-table" over and over as if we had just invested in Rosetta Stone: English edition.

--By Mariam, who has returned from blogging hiatus.

The Curious Case of Benjamin *snore*

I'm so sorry to have taken so long to return to blogging, but there was no way to wake up and motivate myself after seeing The Curious Case of Benjamin Button back in January with Mariam.  Mariam convinced me to see this movie, citing it's numerous oscar nominations.  I wanted to see the seemingly endearing old people romance Last Chance Harvey, but Mariam told me that movie was just for old people.  The problems with the Benjamin Button movie were obvious to me upon hearing the concept of the film - there is only one point in the movie where pedophilia isn't an issue.  Yeah, I know the mind of old Benji isn't the same age as his appearance, but while it might be appealing in the short story by F. Scott Fitzgerald, it's extra creepy on film.  The beginning involves a deformed old man baby hanging out at an old folks home chilling with other people's grandkids, and the end involves Cate Blanchett holding her old man baby lover at the same old folks home.  You may go into the film thinking that at least I get to look at Brad Pitt for 3 hours, but you have to endure the first two hours waiting for the guy you swooned over in Fight Club and Meet Joe Black to emerge.  You are staring at a scientifically impossible ugly old man baby for far too long, and I don't know how this film could have been inspired by a SHORT story.  I simply have to agree with Jon Stewart's assessment of the insomnia curing film, "It's Forrest Gump meets (snore)." Now that I've finally emerged from the coma this movie induced, I hope to return to telling humorous tales of the adventures of a 3rd year medical student.

--by Farrah, who recently got to watch the extremely messy, sloppy, and bloody miracle of childbirth