post-op day seven

Ah, surgeons. 

I never thought I'd want to go into surgery. Ever. It never sounded fun to me. It was never fun to me before going to PA school and it continues, surprising no one, to be about as fun as shoving my head into a revolving doorway. Maybe it's that I'm disappointed. Saddened and let down that surgeons and surgical staffers reinforce, daily, the negative stereotype I hoped to see undone a little bit. Maybe it's the paradoxical abstraction that surgery is for me. That, despite everything, even though you open up the chest or the vessels or the belly, you have to sew them back up again, and then you have no way of seeing, of having some kind of concrete knowing, that what you've done was better than what was before. I mean, you can. You have indirect parameters that indicate whether the patient's outcome is now better or worse than it was before. Whether they spike a fever, become increasingly painful, the amount of fluid accumulating in their drains, the way their incision looks. But it's all going on deep down and underneath, and you can't go back in there without inflicting more trauma.

Perhaps it's simply the barbarism of cutting someone open, splaying out their vulnerable insides, putzing around with their guts. Perhaps it's the fact that I feel the need to wear a jock strap just to anneal myself for morning report, that the arrogant, testosterone-riddled chest puffing is positively aromatized and you can feel it hanging in the air around you, clinging to everything. Perhaps it's that I don't understand why humiliation and venom and vitriol are necessary learning tools and that I've never once seen the need, or good, of hazing. Perhaps it's that I find little else more frightening than hubris and impudence, the inability to consider the failings of oneself. 

This week my surgical team was lead by a senior resident who conducts morning rounds in the same way you or I would hock a loogie. Sometimes we're lucky and he speaks in a muted, wordless language discernible only to dogs and three rare species of Pacific Northwest Humpback Whales. The rest of the time, he scowls and screams. He is the kind of person who stands by the door and waits for you to open it, is two inches from the gloves but will stare at you from across the room if you don't walk around the ventilator, tripping up in the arterial lines and fluid bags and blood products, to hand the gloves to him. We all tromp in, all eleven of us, in scattered formation and at 6:30 in the morning. We flick on the lights, throw down the bed covers, inspect the incisions. We prod and poke and say, "DOES THIS HURT? RIGHT HERE? WHAT I'M DOING TO YOU? LIKE THIS? IS THIS HURTING WHEN I PRESS MY FINGER INTO YOUR GAPING FLESH WOUND? WHAT DO YOU MEAN YOU'RE NOT SLEEPING? OF COURSE IT HURTS, YOU JUST HAD SURGERY".  We strip off the bandages, rip off the tape. We scurry around with gauze and bandage material and boxes. The only things we care about is if someone has been able to fart, shit and is not vomiting. Everything else? Oh, your mother died in a freak meteor accident while you were on the table and now you don't want to go on living? Sucks--and then whispered to the third year: get a psych consult this lady is crazier than bat shit in Ecuador. Actually, he didn't say that. Because that would be kind of funny and nothing about my days are funny. He just stared at her and then told the residents to change her pain medication because he didn't think the morphine "agreed" with her.

Above everything, I guess it's the persistent, consistent, complete separation between patient and surgeon that is perpetuated completely and absolutely. There is rarely a previous relationship, hardly an understanding of the patient beyond their ruptured gall bladder, their obstructed intestine, their malignant mass. In too many ways, we are allowed (encouraged) to forget that our patients are people beneath the sterile, blue draping and not just discrete organs that need resecting or repairing or replacing. It is frightening how quickly you loose sight that what you are doing is mucking around in a human, not just looking for the great vessels of the spleen. In favor of focus we have created a single mindedness that is at its best insensitive and at it's worst, humiliating. 

But in the end, it isn't just the cutting people open, the scalpel to skin aspect that I have such a great disconnect with. It's the willingness to work one hundred and forty three bazillion hours a week, to completely forgo sleep in its entirety, the mutant, alien ability to circumvent the otherwise universal need for glucose, the penchant for sustaining excruciating, tortuously painful physical postures for hours at a time. I know that one way of looking at life in surgery, the most optimistic, is to focus on the fact that you have this incredible access of being able to fix people. They come in, they need to be splayed open and repaired, you do that, and then you leave. Another way of looking at it is that you intentionally inflict onto people enormous amounts of pain. Every step of the way. Ultimately, the cost to do this, to work in surgery--the expense in years of life, personal relationships, the humanity lost, sleeping for little more than 17 hours a week---is too great. Some people want to do it for money, others for a more intangible reward. There are so many people for whom surgical jobs and surgical residencies are the be all end all of their entire lives presently. For me, however, if medicine as a whole were anything like fishbowl of surgery I am certain that I would not be where I am today, surrounded by text books, calling this my life.

bleary

Sometimes New York is magic. All I can say is: post-call, 32 hours straight in the hospital, so f-ing exhausted I almost left my eyeballs in the SICU, can't move, too tired, too cold, stupid wind-chill, negative twelve, no cat food, no milk for coffee ohmygodpetstoreandgrocerystoredeliverysleepalldayinpajamas

opendoorshovemoneyatpersonTHNXbye.

One. Hundred. Percent. Genius.

the green mile

On the top floor, at the very end of the stairway, through the green halls and in dark rooms, is the place they come to die. Above everything else in the hospital, far from the ground and closer to heaven, this is where the knowing, hopeful end occurs. It is here, on this small ward, behind these standard issue double doors and in a way unlike any other part of this building, that people come, to wait, to die.

I come here regularly but am never allowed to pause, because this is not my service, these are not my patients, and there is much mindless paper chasing to be done and it is my task to complete it. I come for small pieces of things, records, reports, vitals. And I walk down the dark halls, looking delicately in, passing too quickly those on the other side. It haunts me, walking by, passing----not stopping, not stopping---not pausing long enough to somehow, in a way I am powerless to fathom, take note, acknowledge, recollect.

Sometimes I do not know if I have what it takes to live a life like this in medicine. Sometimes it seems nothing short of barbaric and cruel, heartless and inhumane. Sometimes, all I can look at in front of me, is our misplaced humanity, the steely fallout of our best intentions. That in our efforts to help, and in our need to galvanize our own persons, we manage to forget that we are all the same species, we are all the same thing; that it will one day be us over there, on the other side, in the dark room, at the end of the green hall, waiting out our own lives, waiting out our deaths.

cabin fever

I don't know, maybe it's all the grey. Sky, clouds, street, roads, buildings, people, noise. The continual, connected, immutable always-ness of the city. Always on, always lit up or tore down or on show, for something, the ever unquiet world of New York. Maybe it's that my apartment is like a lovely prison--perfect, warm, oppressive-- or that on the rare and lazy thin winter Sunday when the sun does come out, there's no place to go that doesn't exchange currency for space, no unlit, open, uncomplicated place. Maybe it's that every time you walk out the door, there is noise. Somewhere, right there, every time, always. The expressway, the tunnel, the tracks, the passes. A horn on Clinton Street, a truck breaking, a car, a bus, a train, a siren. There is, nowhere around me, the open-endedness of space, an uninterrupted sky or ocean or water. There is, all and only around me, a claustrophobia of stuff.

fever dream

You know those last few pages of Into The Wild where Chris McCandless is deliriously scribbling his final, dying thoughts into his journal before taking his last, raspy breath? Yeah well that's what it's been like around here the last couple of days. I can't say for certain, but I highly suspect that yesterday's fever was the equivalent of seventeen full length Grateful Dead shows in terms of brain damage sustained and not only is it now confirmed that I will be waddling around in enormous Adult Diapers by the time I'm 80 but I'm also going to be on dialysis because I straight up blew out my kidneys with Nyquil. 

So, for the record, Dengue/Scarlet/Small Pox/Yellow Fever sucks and I highly recommend not getting it. Really. Much like Meth, it's retarded to even try. It's probably better to put your head in a blender, I can promise you it would feel better.

And! AND. While I was probably going to stay home today anyway, milking the phenomenal level of sympathy and kindness of my preceptors for all it was worth, as it turns out today is an official snow day and we were given the day off. Officially, and shit. Because New Yorkers are unbelievably woosey and can't negotiate life in the city with 4 inches of snow. And hur-friggen-ray.

So now I'm going to bake a cake. Because tacking at a body temperature of 103.2 F for 96 hours burns you some calories, yo. 

So apparently I have EBOLA and had to stagger desperately home this morning after trying to crawl into someone's locker to get a little shut-eye already because the 3rd year med student I'm on team with this week is such a fucking incompetent retard pansy special person and acted like I'd just thrown her grandmother into moving traffic at the mere suggestion that I might go home because the last time I checked, spreading your Meningitis/Hanta/Nipah viral slime all over the greater parts of large urban hospitals is pretty much frowned upon. 

And then some kindly attending took one look at me and promptly told me to "get the fuck out of here before you infect all of us you $#@*% idiot". So that was awesome and reassuring and about as warm fuzzy inducing as a dinner date with Mao Tse-tun. 

But I did go home, after passing out on the subway and being kicked awake by some drunk bum who was angry because I was sleeping in his urinal and have a little decorum, please. And went immediately to bed where I slept for nine hours straight and you know the craziest thing of all? Cats can sleep forever. I got home at 9:00 am, slept until 6:00 pm, straight, and when I finally stumbled up and out to drink some fluids or eat some chicken soup or whatever it is people are supposed to do when they're dying a slow and feverish death both of the cats are all, "jesus lady, you don't have to be so fucking aggressive about it". 

surgical work ups

Thursday was a @#$%^$ ass kicker of a day. Surgical people are such strange, sadomasochistic, single-minded, abusive, abused, unrealistic freaks. To start, I wake up at 3:45 am. My clinical day doesn't begin officially until 5:45 am, but my day officially, officially, officially begins at 3:45 am, when my eyeballs are open.

And that sucks.

Second, I'm still not better. I'm not hallucinating, I'm no longer channeling satanic forces through a massively febrile state of altered mental status, but I'm not better. My throat is quite seriously threatening to expel itself from my body in what would certainly be an impressive display of blood and gross stuff and some really cool and previously unknown mechanics of auto-amputation. I'm almost certain it would get me top spot on the roster for Friday afternoon Morbidity and Mortality. And, I'm a fucked up and curious enough human that, if I could, I would almost goad it on. 

Third, surgeons habitually disregard reality as we know it. They're kind of like Jersey Used Car Salesmen, only, not at all. Oh, you've been cut into five different, unequal pieces? No problem, we can totally fix that. And thank god, you know. Because Krishna knows that whenever I'm cut up into five different, unequal pieces, I really appreciate their optimism. At 5:45 in the morning, though, the optimism that I actually can gather up all the labs, CT/MRCP/ERCP/MRI/XRAY results, pathology reports and over night vitals on 15 different patients spread out over 6 different floors in a hospital that has centrally organized ABSOLUTELY NOTHING onto a conveniently located computer system, in 15 minutes? 

Not so much.

Because 7 minutes into sprinting up and down the stairs to all sixty million different areas of the hospital where the information is separately and surreptitiously squirreled away in esoteric and poorly labeled locations and scribbled by hand in sanscrit and then lorded over by nurses who will fuck you up if you even think about moving anything from its clearly obvious place, I basically want to shove a scalpel into my own eyeball and wash it down with a shot of rubbing alcohol. 

And then. AND THEN. After failing this "pathetically rudimentary" and "simplest of tasks", the surgical residents take prolonged and bowel-hurl-inducing exquisite glee in determining who, based on our abilities to perform ingratiating an illegal tasks in exchange for vital information such as, say, the blood pressure on patient A in Bed ___ of the SICU on Floor __ (really people, I don't even want to know what CIA agents have to endure to find out information any more covert than that), who gets to scrub in on what surgeries, and when.

And I can't even tell you what a hungry, future surgeon, 3rd year medical student will voluntarily do to themselves and others, for the divine privilege of watching someone's gallbladder come out. It's unfuckingbelievable. 

But I am not a hungry future surgical third year medical student. Which is an amazing, exceptional place to be, because I am quickly learning that people can only abuse you if you let them. And if you don't actually give a furry little rodent bottom about inguinal hernias and the vastly astonishing ways that we repair them, it's hard to get beat up. And this, my friends, is truly amazing. Because nothing infuriates a Czar Surgeon fourth year surgical resident more than not being able to distribute sweet, sweet torture. 

Resident: Okay children, listen up! If you don't get all your vitals and labs and results and reports prior to morning report, and by prior I mean 5 MINUTES BEFORE WE START, morning report you will not be able to scrub into surgery. And you will have to stay on the floors, see all the patients in recovery, you will have to talk to them, you will have to examine them, you will have to write progress notes in the charts and you will have to follow up on their recoveries, their pathology reports and their pain management. DO YOU UNDERSTAND????

So my punishment, if you will, was to stay on the floors, with sweet fourth year resident Dr. P, who cares way too much about people and I have no idea why he's completely sacrificed his life (really, literally, sacrificed. Life? Gone. Nada. Zip. Four am to eight pm. Six days a week. Forever.) to cut up unconscious people. It friggen baffles me. 

And all we did, all day long, was run (not figuratively) around the hospital, checking on this or that, consulting on a patient here, arranging surgery on a patient there, trying to determine why patient A is bleeding out on floor C and why surgeon X won't take him any sooner than, hmm, next week, by which time he will be exactly 6 days expired. He sent me to do a number of different consults on my own (which scared the CRAP out of me because what if, oh, I don't know, I'm WRONG and they actually do need surgery, like, this instant) and I can organize the hell out of anything, so it felt better to be useful. And honestly, even though it would get old after a while, existing in a vast world of spinning micro-management, I rather do that all day than just standing in a sterile room under scorching lights for seventeen hours, not being able to scratch your own nose or pick your wedgie, looking at people's shiny pink insides. 

nuchal rigity

You know those days when you get on a plane to go to California from New York, watch 6 1/2 hours of Animal Planet straight, openly sob into your Taro Blue Potato Chips when the Pedigree commercials come on that get you right in the fucking solar plexus (and don't even SAY THE WORDS "that ASPCA commercial" because I friggen lose it just thinking about it so just stop it right now) and every rerun of Animal Precinct makes you realize that ALL YOU WANT TO DO is pack heat and save dogs and then you spend just enough hours in California to get fat on huevos rancheros and margaritas, come to terms with the fact that you miss the ocean like it was a kidney, get back on a plane from California to New York, watch five more hours of Animals (in peril) Planet, get out of the plane, it's -17 degrees, the cab line is fifty million people deep and you didn't bring a hat and by the time you make it home all the take out restaurants are closed and you don't even have cheesy mac in a box and you have to get up the next morning at 6am to get on another plane to New Hampshire to look at the house you bought and hopefully still really really really like many hundreds of thousands of dollars really love, almost get kicked out of school for shirking off on your clinical training and escaping only by the grace of god or someone who just works for him, getting back on another plane back to New York, spike a 102 temperature, start hallucinating, begin your first day of surgery a day late at 5:00am with a core body temperature of 101.7 F (despite 5,000,000 mg of Dayquil) and active rigors, make nice with the residents, literally FLEE during afternoon rounds by running down the back stairs because the whole light/end of tunnel/angel of death thing is going on in front of you and for once its not your patients and so you crawl home on all fours through the snow to get into the bath and there's no hot water and by the time your husband comes home you are speaking in tongues and have swallowed half the bottle of Nyquil and thank god he's there because lord knows the cats can't pick you up out of the bath tub because they have no thumbs and then you proceed to sleep sweat profusely for 11 hours straight only to wake up 99% convinced that, dude, you have meningitis?

Man I hate when that happens.

letter d

So it occurred to me today that we throw a lot of d words around in medicine. For instance, during the course of reviewing hyponatremia (a DEFICIENCY of sodium) alone I came up with ten --deca-- different ways to say "shit's fucked up" using, exclusively, words that start with d:

defect

deficit

deficiency

depletion

disorder

disregulation

damaged

decompensated

deformity

degenerative

Then there's the standard, garden variety disorganized, disproportionate, debilitated, debris (debride), decapitation, decay, decerebrate, delirium, as well the more exotic and alluring:

1. Decipara ~ a woman who has given birth for the tenth time to infants, alive or dead. Notice that they have to CLARIFY that she's given birth to infants, and not, say, kittens. 

2. Dactolysis ~ the spontaneous amputation of fingers or toes. As seen in leprosy, ainhum and produced in utero. Holyfriggencrap. 

3. Deutromycotina ~ the phylum of imperfect fungi. 

And then, my personal, all-time favorite:

Defecography ~ Radiography of the ano-rectal region after instilling barium paste into the rectum. The defecation process is [then] imaged by direct filming (fluroscopy) or video recording. No way.