BRAAAAAAINS!

My week on neurosurg is almost over. I can’t say I’m disappointed. While the concepts behind the surgeries are interesting — why that approach? what’s the indication for surgery? — there is only so much enjoyment you can get out of watching someone scoop out a tumor. (My new requirement for picking which surgery to watch: there must be a case going afterwards. Ten hour surgeries are not my cup of tea.)

The surgeons, though, are hilarious. Sample conversation:

RESIDENT 1
Dude, this scope isn’t working.

RESIDENT 2
Dude, you lost your mojo!

RESIDENT 1
Duuuuuude!

ATTENDING
Hey Aussie-Boy [the sub-intern is from Perth], turn up the music!

[Sub-i scrubs out and adjust the iHome, which is nailed to the wall.]

ATTENDING
Why is this playlist so random?
*pauses in his tumor-scooping and reflects*

ATTENDING
It’s like the 1970s. One minute you were listening to Black Sabbath and then suddenly it was the BeeGees and you had to go buy a leisure suit. You remember those, James?

JAMES, THE SCRUB NURSE:
I think we’re showing our age, sir.

RESIDENTS 1 and 2, and AUSSIE-BOY
DUUUUUUUUUDE!

Washing hands

Doctor and Patient – Why Don’t Doctors Wash Their Hands More? – NYTimes.com.

Surgeons are, with good reason, the most hand-washing-happy crowd I know. Today I was with a surgeon in his office hours, and he did a minor procedure on a patient but was nevertheless as careful as he is in the OR.  Autoclaved the instruments.  Placed everything just so on a blue sheet.  Even got the special surgery gloves, which come individually wrapped (like gift chocolates, but made of latex!) instead of the standard ones on the wall.  He also prescribed the patient Levaquin afterwards, saying to me after she’d left the room, “I didn’t see any breach of sterile technique, but you can never be too careful.”

(Ok, overuse of antibiotics might be an issue.)

Bottom line is well summed up here:

Hand hygiene and sterile technique are so successfully maintained in operating rooms not because of the reminders that hang over scrub sinks, but because it is part of the culture and identity of those who work there.

For the rest of us, those Purell sanitizers are key.

Of subways and sutures

I was reading my urology textbook on my subway commute yesterday, and I suddenly realized that the person sitting next to me — a 12ish year old boy — was staring in horror at the figure entitled “Circumcision of the Adult Male.”  Poor kid.  I should probably stick to 19th century novels for my subway fare.

Awkward moments with strangers aside, I’m really loving this rotation so far.  My chief resident is superb — she encourages me to see clinic patients solo, she insists that I scrub into every non-scope surgery, and today when I asked her for recommendations on practicing suturing, she said, “Here, let’s change places,” handed me the needle driver and the toothed forceps, and walked me through everything with infinite patience.  She even let me close with the staple gun!

Another med student rite of passage over!  Before you know it, I’ll be graduating with Actual Skills under my belt!

“We don’t care what they say.”

Sometimes, as a student, you see an interaction between a doctor and a patient that makes you shudder. And sometimes you see something that makes you proud to be in this crazy profession.

Clinic

Every rotation (except, I guess, psychiatry) has a free clinic, where the residents see Medicare and Medicaid patients.  The med students tag along and there’s also an attending present, of course, but really the residents are the ones running the show.

What we get to do as med students really depends on the resident. Most of my neuro residents were cool about letting me do my own history and physical then presenting to them.  My ortho resident today was more of the “Med student, you stand over here and watch” type.  They are quite protective of their patients, these orthopods.

More than anything, I’m aware of the difference in care that you get in the free clinic versus the attending’s office hours.  In office hours, you see the same physician every time.  There is continuity.  In clinic, it’s just whoever is available; the residents always check the electronic record for previous clinic notes, and it’s certainly adequate care, but it’s not consistent. Then the residents and attendings sit around afterwards and gripe about how Paul Bunyan* is non-compliant with his follow-up appointments because he’s too busy chopping down a forest to come to a clinic and repeat the story about Babe the Blue Ox stepping on his forearm.

Would better continuity improve compliance? My guess is yes; seeing the same physician every month would set up an expectation of personal care.  But when it’s as random as your supermarket cashier, why should you bother showing up?  Maybe I’m being naive, but it does seem bizarre that we worry so much about continuity in an inpatient setting (e.g. resident work hour restriction) but totally ignore it for ambulatory care.

*I would love to have a patient named Paul Bunyan. But I guess then I couldn’t use it as a pseudonym anymore….

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Kaplan just sent me an email entitled STEP 1 LECTURE.  Thankfully, GMail dumped it straight into spam. 🙂

The more I think about this rotation, the less I like it.  I don’t like the ad hoc nature of it, and though everyone’s been welcoming and friendly, I’m just not a surgeon. Part of the issue, I think, is that students are not really part of the team.  We watch surgeries (whenever we feel like), we attend clinic (whenever we feel like). But we can arrive when we want, leave when we want. I think it’s nice that we get to set our own schedules, but I miss patient care. In this field, it’s not so much “my patient” as “my rotator cuff repair.”

White-wash this fence

So surgeries are actually kind of fun!  Today I saw bilateral total knee replacements and the first half of a bilateral hip replacement surgery, and — to my surprise and credit — didn’t pass out.

Thoughts on the OR:

Career development?

I just attended a talk about trauma surgery. It was less about what it’s actually like being a trauma surgeon (though he addressed that during the Q/A at the end) and more “This is what you need to do to pass your surgery boards.”

He also had a ton of frightening pictures of people with mangled body parts and poles sticking through them and whatnot. It was not a pleasant sight. Trauma surgery certainly sounds kind of cool, and I’m sure it’s incredibly rewarding, but I’m not exactly thrilled at the thought of gashes across faces.

There were several pictures of failed suicide attempts (slit wrists, one throat cut so deeply that they were able to intubate directly through the wound, etc.) which just reminded me of something a friend of mine, who used to work with a crisis hotline, told me. They got several calls about suicidal ideations, and once they established that it wasn’t an imminent danger and that the person really just needed to be talked out of it, they would “de-glamorize” suicide by talking about what would happen if it went wrong. Such as, “If you slit your wrists, you could end up with necrosis or sepsis in your fingers and would have to have them amputated.” Apparently it worked quite well.

What interests me more than the immediate surgical intervention is the longer-term psychiatric implications that would lead someone to suicide. As a matter of fact, I am going to the student section of a psychoanalysts’ conference on Saturday. Although of course I don’t know that I want to become an analyst, or even that I like psych that much (though on paper it sounds fascinating), I figure it can’t hurt to explore a little before third year. Also, this is New York City, where even analysts have analysts. It should be a good program.