Random Thought of the Day

I waste far too much time wondering what my dog is thinking about.

It's Official... I've Defected.

There aren't many people out there likely to find this even half as big a deal as it feels like to me. But I've changed programs.

I am no longer an emergency medicine resident. Well, not really. I am now a family medicine resident. But since I have every intention of doing a third year of emergency medicine training when I am done my two years of family, I've really just gone from being an emerg doc in five years to being one in three.

Considering that it's a pretty minor switch, in the grand scheme of things, it's awfully symbolic. I've had it with academia. I have no patience for the egos or the politics. I just want to get out of the city and practice medicine. Not medicine with research and administration, just medicine. See, the five year program approaches emergency medicine as a four-headed being-- clinical medicine, administration, research and teaching. In spite of my best efforts, I could never warm up to administration. And I did make an effort... the sole reason I became a union rep was to see if there wasn't more to administration that I wasn't seeing. Now I'm locked into an elected position that bores the crap out of me for the rest of the year. So much for administration.

Research? Well, everyone assumed that since I'd done a very research-oriented master's degree before medical school that I'd take to it like a duck to water. Instead, I'm left with a very PTSD kind of thing. I realized it a few months back when I was assisting in a c-section, and the obstetrician was talking about her latest grant application. I got a viceral reaction... immediate nausea. I hate applying for money, I hate the literature searches, I hate the way you have no control over the pace of your work, I hate the pressure to publish... I hate all of it. Not good when you're expected to go into academic practice.

So I started to think about it. What kind of practice do I see myself having in 10 years? Easy. I want to practice emergency medicine in a smallish town (think Milton, Peterborough, Kingston, Orillia, Barrie, Sudbury). No research. I don't want to run the ER. I might like to continue teaching informally, like by supervising residents, but not by teaching at a university. So then I came to the realization... what the hell am I doing in the academic stream?

The 2+1 program (one year of emergency medicine after two years of family medicine) is far better suited to what I want to do. I can work in all but the biggest academic centres (even the place I'm at now has as many 2+1's working in their ER's as 5-year grads). I won't be under constant pressure to do research. I won't have to take on an administrative role that I don't want. And best of all, if I ever get burnt out (like everyone says I will... it's apparently inevitable) I can do locums or work in a walk-in clinic, which is far more appealing to me than doing research or administration full-time.

So it's done. Once I had made the decision, all that was left was going through the paperwork and telling people. That was the worst part. I was so tied up in knots over telling my program director that I didn't eat for two days. The past month has been a flurry of meetings, wheelings and dealings. I've been back and forth between the department of family medicine, the department of emergency medicine and the postgraduate education office more times than I care to think about. But now, all there is left is to submit the paperwork and have it rubber-stamped, all of which is out of my hands.

I change programs on January 1st, 2006. Hopefully this knot in my stomach will have subsided by then.

Here's a Secret...


... People wake up during surgery ALL THE TIME. Well, when I say 'wake up' I don't mean they sit up and start chatting with the surgeon about last week's episode of Survivor... but more awake you'd think.

I don't remember when the first time I saw it was, but I guess it was back when I was a med student. If you're not warned beforehand and the patient suddenly starts bucking, it is a truly scary thing. At the time, what shocked me even more was how nonchalant everyone was about it. The surgeon calmly called the anesthesiologist's attention to the fact that the patient 'was a little light'. This wasn't readily apparent to the anesthesiologist because once the patient is asleep they are likely to be napping, reading a book, doing a crossword puzzle, checking their e-mail, talking on the phone, or, in one of my most bizarre OR experiences to date, constructing an elaborate tent out of sterile drapes and towel clips to shield themselves from a draft.

So the anesthesiologist, alerted to the fact that their patient seems to be two seconds away from taking the scalpel from the surgeons hand and circumcising him with it, calmly drew up a little more rocuronium (paralytic) and injected it. Crazy. Now usually, there would be signs that the patient was not as deeply under anesthetic as he should be... in response to pain, even unconscious people will show an increased heart rate and blood pressure. Usually, the anesthesiologist will pick up on that and top them up, either with stinky gas or with the good stuff (fentanyl, sufentanil). I'm not sure why this time was different. I have a hypothesis though... see my previous post on medical errors.



Luckily, even if the patient DID wake up in the middle of surgery they'd never remember it. The main drug used in anesthesia (the one that actually puts you to sleep most of the time) not only puts you under, but is a pretty potent amnestic agent. (Insert evil laugh here)

So good luck the next time you have to go in for surgery.

Pimp of the Week, Volume II

Today I was pimped on greek mythology. My staff anesthesiologist wanted to know the origins of the words Morphine and Atropine (two commonly used drugs in anaesthesia). When I looked appropriately confused, he hinted that they came from the words Morphea and Atropius (or something like that). I was incredulous... he seriously wanted me to research greek mythology and get back to him? Yup. But at least he was impressed that I knew they were based in greek mythology.

I can only hope that this means I know everything I need to know about medicine and the staff guys are running out of things to ask me.

Anaesthesia-- From the Latin Word for "This Rotation is Putting Me to Sleep"

Okay, I'm determined to say something positive about anesthesia. Today was a good day. Part of that might be because it was the first day I worked this week, and part because it only lasted three hours. Sigh. On Monday I went into work only to find that the ONE operating room that was doing general anaesthetics had already been claimed by a respiratory therapy student. Okay. I went around to the other rooms, but all there was going on that day were a couple of ortho rooms doing spinals and a couple of eye rooms doing neuroleptics (i.e. happy drugs that relax you but don't put you to sleep). So, I went home.

That was the second time in the space of a week that I'd gone in and ended up turning around and going home. This is getting ridiculous. After being told by a staff anaesthesiologist that 'it's expected that residents step down to let the medical students have the good rooms' I had enough. I checked the list for the next day, saw that there was a similarly small number of OR's running, and made the executive decision to stay home.

I'm being paid for this. Yes folks, this is where your health-care dollars are going. To fund a doctor with 11 years of university education to go on a hike with her visiting sister and her dog. To break up the monotony of this post, here's a picture of the dog:



So here is my effort to say something positive about anaesthesia: I may have learned something this month. Today, I did a successful nasal intubation. Pretty cool. It's a tricky thing, so I'm proud of myself. Then, I got to see an 'awake intubation'. Which, unfortunately for the patient involved, is exactly what it sounds like. If you're expecting someone to be SUCH a difficult intubation that you can't risk sedating and paralyzing them, you stick a tube down their throat while they're awake, then put them out once you've confirmed correct tube placement. Another tricky thing... I left that particular trick to the staff guy! It was unfortunate to watch, but the guy had a tumor in his throat that obscured all of his laryngeal anatomy. Calling him a difficult intubation would be an understatement.

Okay, so here's where I learned something. I'm sure this is going to be one of those stories that you really had to be there to appreciate, but I'll try it anyway. So during the last case, the anesthesiologist got called back to the recovery room to deal with the patient we had done previously. I was left alone with the patient. Suddenly, lights and alarms started going off on the big, intimidating anaesthesia machine...



That's not good. All I could figure out was that the bellows weren't filling and he wasn't breathing... this guy was a heavy smoker and didn't have much in the way of reserve, so his oxygen saturation fell pretty quickly. I panicked at first and asked the circulating nurse to call the recovery room and get the anesthesiologist back ASAP. He wasn't there. I tried manually filling the bellows, I tried increasing the flow of oxygen, I tried bagging him manually... nothing. Finally I got my head on straight enough to think the problem through. And I found the problem... the surgeon had inadvertently knocked the tube, and the circuit had come apart from the tube. Phew. Crisis averted.

So there ya go... anaesthesia isn't always boring.

Pimp of the Week

In case I haven't adequately explained the term "pimping", it is the process by which anyone senior to you in the medical hierarchy (an attending, a senior resident or hell... anyone from the janitorial staff) asks you a series of questions getting consecutively harder until you get one (or many) wrong. At this point you are likely mocked and the very basis of your medical qualification is called into question. At my medical school we also called this process "shame-based learning", as it was often done in front of a group of your peers who were likely to watch with barely disguised glee because hey... it's not being directed at them.

So this week the Pimp of the Week award goes to the staff anesthesiologist (haven't I complained about this rotation enough?) with whom I worked on Tuesday. He was older than dirt, and was likely around when anaesthesia still consisted of hitting people on the head with a blunt object. Suitably, he spent the entire day pimping me on medical history. Yes, you heard me right folks. The freaking HISTORY of medicine. When was the first anesthetic given? When was the first laparotomy performed successfully? What was the first local anaesthetic used? What country successfully pioneered the gas induction method? It was like Jeopardy if Alex Trebek suddenly decided to don OR greens and a funny surgical cap.

Of course, since my knowledge of medical history is somewhat lacking (read: nonexistant) not only did I not deserve my medical degree, but it was undoubtably due to bribery that I managed to pass my board exams. I didn't have the heart to tell this guy that not only is there no medical history on the board exams, but that it isn't really taught in med schools anymore.

For now, I'm a little more concerned with learning the medicine that will allow me to not kill people TODAY. I'll worry about the historical stuff some other time.

The Naughty Professor

I think a lot of what is wrong with medical education today is simple-- they allow me to teach it. I mean, really... I'm still learning this stuff myself. My sister said it best at a family event back in September. I announced to my mom, sisters and other assorted family members that I would be teaching a component of the first year medicine curriculum starting the following week. There was a brief silence (I supposed people were trying to decide whether to congratulate me or offer me condolences). Then, from my sister: "Well, that's just WRONG".

Then again, my sister is somewhat sensitive about the topic. She's 29 years old and working on a PhD in an interesting but somewhat useless area of study. She's worked for years to teach at the university level. The idea of me waltzing in off the streets just a few months after completing a measly MD must kill her. Heh. I can't really argue with her, though. It IS wrong. These students are paying over $15K a year in tuition fees alone to get taught by someone with barely more experience than they get from watching ER.

Actually, when I volunteered to teach I kind of assumed that there would be some form of mentoring involved. At my med school, clinical skills were taught by a trio of three doctors from different specialties... a great idea cause it gave us a pretty balanced view of medicine. An emerg doc is going to have a very different idea of what should constitute the physical exam than an internist. I figured they'd pair me (the newbie) with a seasoned veteran of medical education who would show me the ropes. Instead, I became the sole educator to a group of seven fresh-faced youngsters (seriously... I think the oldest MIGHT be 22 years old) each with varying degrees of keener-dom. Sigh. Was that ever me? So naive, so trusting...

Ha. These kids have NO idea what they're in for.

Anaesthesia Continues to Suck...

There is so much I hate about anesthesia, I'm really going to have a rough time keeping this brief. Here's what I'm particularly hating today, though.

Anaesthesia is an art masquerading as a science. Sure, it's all based in hard-core physiology and pharmacology (which, of course, is what I get pimped on incessantly)... but every anesthesiologist does it a bit differently. There's a general recipe for induction of anaesthesia-- One part narcotic, one part sedative-hypnotic and in most cases, one part paralytic. There are different choices for each, the most common cocktail being Sufentanyl, Propofol and Rocuronium (isn't that a cool name for a drug?). But some use Fentanyl instead of Suf, some use Succinylcholine instead of Roc... I won't bore you with any more details, but you get the gist. But this goes WAY too far.

Monday with Staff Anesthesiologist #1:
Dr. Couz secures breathing tube to the patient's upper jaw with paper tape.
SA#1: What the hell are you doing? That stuff is crap! Who the hell told you to use paper tape?
Dr. Couz: Um, sorry. What would you like me to use?
SA#1: The pink tape, obviously. Where did YOU go to medical school?

Tuesday with Staff Anesthesiologist #2:
Dr. Couz secures breathing tube to the patient's upper jaw with the pink tape.
SA#2: What the hell are you doing? Are you trying to rip off ALL of the patient's skin? And who the hell told you to tape to the upper jaw? The tube moves with the LOWER jaw!
Dr. Couz: Um, sorry. I'll use the paper tape.
SA#2: That stuff is crap too. Use this. (SA#2 inexplicably produces a roll of seemingly identical tape from his pocket and secures the tube to the lower jaw)

Wednesday with Staff Anesthesiologist #3:
Dr. Couz secures breathing tube to patient's lower jaw with used chewing gum.
SA#3: What the hell are you doing?

You can see where this is going.

I don't entirely understand why people are motivated to go into anaesthesia. You draw up some drugs, shoot them into people, and sit around for the rest of the surgery doing a crossword puzzle and hoping to hell that nothing goes wrong. I'm amazed that more anesthesiologists aren't raving drug addicts. Three weeks of anaesthesia and I'M tempted to stick a random syringe into my vein just to keep myself awake. Sigh.

Can I do some emergency medicine now? My short attention span can't take much more of this.

Random Thought for the Day

When women come into hospital to have babies, I never cease to be amazed at how many of them have the presence of mind to engage in meticulous pubic hair grooming even when unable to see their own genitals. Not everyone, mind you, but enough that after a couple of weeks of obstetrics I asked one of the attendings if they asked their patients to shave at least partially before coming in to hospital (her answer was no, and a puzzled shake of her head-- it's okay, I'm now used to asking stupid questions).

Men, on the other hand... not so much. I spent one day in a urology OR, where it was apparently vasectomy day for men unable to have anyone handle their delicate members without general anaesthetic (can you SEE me rolling my eyes out here?). Not ONE of them even thought to trim their giant bush of pubes. Lovely. So instead, the nurse does it and they end up with a half trimmed wang.

Are men just lazy, or are women just more conscious of personal grooming?

Discuss.

Mr. Jekyll becomes Dr. Hyde

I don't think anyone will argue with the fact that a disproportionate number of physicians out there are pompous assholes. When I say disproportionate, I mean that when you compare the number of assholes per hundred physicians, it seems to be much higher than the per capita number of assholes in any other profession. Way back when, some of my medical friends discussed this topic at length. Does medicine select people with pompous tendancies, or does the pursuit of a career in medicine make us this way?

I am currently doing a month of anaesthesia. In theory, anaesthesia is an incredible learning opportunity. (Newbie note: anaesthesia is the area of medicine responsible for the patient's vital signs-- breathing, blood pressure, heart rate, etc.-- during surgery. Basically, it's the doctor who puts you to sleep.) You have an entire day of what basically amounts to one-on-one mentorship from an anaesthesia attending. You're there for every step of the patient's operative care from the pre-operative assessment to the post-anaesthetic care unit. It's a great opportunity for someone in emergency medicine to learn about pharmacology (they have all the best drugs), fluid balances and ventilation, and a great chance to learn and practice skills like intubating, starting central lines, starting IV's, lumbar punctures and other crazy things that I still can't believe they let me do on real people.

Instead, I'm hating every minute of it. Every anesthesiologist I've worked with is an ass. Instead of taking the time to teach me things, they humiliate me for not already knowing what I'm doing (in my first week, natch). On my second day, I asked the staff guy I was with why he used Sufentanyl when the guy I'd worked with the day before had used Fentanyl and here is what he told me: "I'm not here to answer your questions". I shit you not. Dude! You work in a freaking ACADEMIC CENTRE. You are employed not only by the hospital, but by the university. IT IS YOUR FREAKING JOB TO ANSWER MY QUESTIONS. What an ass.

The guy I worked with the next day was no better. He basically went about his day and completely ignored my existence. It wasn't the best room... long surgeries. This isn't as much fun for me since the only time I really do anything is during induction (putting people to sleep at the beginning of surgery). But two of the three patients needed everything for their surgery... epidural, arterial line, central line, intubation and general anaesthetic. A gold mine of procedures for a rookie... particularly one in emergency medicine who needs to become proficient in them (except epidurals... that's strictly an anaesthesia thing). But what does this guy do? He does every single thing himself, silently. Doesn't even explain what he's doing as he goes along. Here I was, trying to get close enough to see without contaminating his sterile field, and he was just going about his business like I wasn't even there.

Sometimes I hate the "culture" of medicine. The rigid hierarchy, the unfriendly rivalry between specialties (not to mention the way all specialties seem to look down on family doctors), the pompous asses that seem to be everywhere you look...

I'm hoping to God that this is just a tertiary care/academic centre thing. I'm really counting on the fact that when I get the hell out of here and start practicing in a smaller town away from the academic bullshit that this will all go away. For now, although I love my job, I'm really dreading going to work in the mornings. Sigh.

My Dirty Little Secret:

I love Grey's Anatomy. Like many other medical professionals, I spent the first few episodes yelling at the TV. I tuned into the first episode out of curiosity, then watched the next few to see what new medical inaccuracies and ridiculous stereotypes they could come up with. Now it's season two... and I'm still watching. Sigh.

Today I came across a great article written by two residents in the states about the more damaging errors portrayed in the show. I'd just link to it, but I'm afraid since I found it on MSN it would disappear after a few days. So here's the article, credited where credit is due.

Paging Dr. Welby: The medical sins of Grey's Anatomy.
By Ingrid Katz and Alexi Wright

This patient has an acute case of incredulitis. Perhaps if I kiss her..."

On the season's first episode of Grey's Anatomy, surgical intern Meredith Grey was drafted to help a pediatric surgeon, who happens to be her boyfriend's wife, operate on a pregnant woman, who happens to have lost her husband to an affair. Genius. As doctors, though, we haven't been dreading the show's reappearance because of its silly plot twists. We have a professional beef with Grey's Anatomy: Along with House, the other hospital show on the air at the moment, it is medically far-fetched and misleading. Most of all, we dislike the show because it loses sight of the point of any medical enterprise—the patients.

...

In last season's premiere, blond and attractive Meredith Grey oversleeps on the first day of her surgical residency after a one-night stand with a stranger—who later turns out to be her boss. As the show unfolds throughout the season, the two struggle to stay apart, soap-opera style. Meanwhile, Grey and her fellow interns suffer through the humiliations of residency, from an abusive chief nicknamed "the Nazi" to a hospital-wide syphilis epidemic started by a surgical intern.

Many moments would make the old-time AMA vetters cringe. Instead of asexual father figures, the doctors on cast are hyper-hormonal. Attendings sleep with residents. Interns bed nurses. Even patients are fair game. On one episode, Grey kisses an injured biker brought in to the hospital after an accident involving spokes sticking out of his abdomen. Normally, any of these infractions would be grounds for dismissal. At Grey's hospital, they're all in a day's work. These breaches, however, are minor. What matters are the glaring inaccuracies in complicated and delicate areas of medicine. In one egregious episode, the character played by Sandra Oh, Cristina Yang, asks a woman to donate her husband's organs after he dies unexpectedly. Yang botches the job, dispassionately asking for the husband's eyes and skin as if they were no more than items on a grocery list. Then she runs out of the room as the wife begins to cry.

The scene is rife with errors that could damage public perception of organ donation, starting with the premise: Yang is angling for the husband's organs because another patient (who also happens to be a close friend of the chief of surgery) is dying from liver failure and will be saved if the wife agrees. In real life, hospitals go to great lengths to prevent exactly these types of conflicts of interest, barring doctors from approaching patients directly and designating statewide organizations instead of individual hospitals to distribute organs. Maybe we're just two overeducated doctors who take television too seriously, but we worry that this plot line could have done real harm by discouraging people from donating.

In another episode, two of the characters experiment on a patient, performing an illegal autopsy against a family's wishes. On the show, the characters are forgiven, instead of arrested, because they discover the patient had a rare genetic disease (which Oh blithely mispronounces). But as doctors, we could not forgive the producers for their superficial all's-well ending. Since the Tuskegee tragedy, doctors have instilled institutional checks to ensure that clinical research is ethical. Still, many patients avoid doctors because they are afraid of being experimented on. The autopsy on Grey's Anatomy's casually corroborated their worst fears.

Watching these episodes makes us long, in spite of ourselves, for the days when the AMA had television producers on a tight leash. Don't get us wrong: We don't miss Dr. Welby's starched white coat. But we are afraid that TV's worst inaccuracies may compromise what trust remains between doctors and patients.

A few months ago, one of our patients left the hospital emergency room before getting treated because he did not want to miss a Grey's Anatomy episode. As he signed out against his doctors' advice, he reminded us that medical shows are sometimes better than patient realities. Maybe so. But the patients are what real doctoring is all about.

Ingrid Katz and Alexi Wright are medical residents at Brigham and Women's
Hospital in Boston and clinical fellows in medicine at Harvard Medical School.

Seriously. This show has been driving me crazy since the outset. From the first episode, where all of the surgical interns are on call the same night (wha?) to this week's episode, where there were so many ridiculous aspects to Sandra Oh's 'ectopic pregnancy' I couldn't concentrate on the plot, this show is so inaccurate it makes my teeth itch. Granted, I'm a stickler... it drove me crazy when they said she was in danger of losing her RIGHT ovary when the surgical board (where doctor I-have-a-large-stick-up-my-ass first learned of her pregnancy) clearly stated LEFT salpingo-oophrectomy.

Sigh. I am such a geek it hurts.