For once, not on me.
No, I'm on my required surgery rotation. I'd been warned about the bad hours - the extensive standing around holding a retractor and not being able to leave to go to the bathroom or scratch that itch on your nose because you'll contaminate yourself. I was expecting to be miserable, and I've surprised myself in how much I'm liking it.
It's at least in part because my last rotation was pediatrics which I loathed despite the decent hours and a nice preceptor. Any rotation that meant I no longer had to deal with screaming children and obnoxious parents would be glorious, but surgery in particular is the most interesting rotation I've done thus far.
For once I actually feel like I'm doing something, even when it's something as small as putting in a couple stitches, holding a retractor or suctioning - what I'm doing actually helps to some degree. I'm no longer just writing notes that no one reads or watching someone else write orders all day.
Actually feeling like I'm doing something useful - what a revelation!
I was in on a total hip replacement recently. I was a little more complicated than a routine replacement, and we were in the OR for a little over 8 hours. My feet and back were killing me less than half way through but there was no way I was going to scrub out and miss any of it. Seeing all the structures in the hip in a way I hadn't looked at them, even in anatomy, being there for all the intraoperative decisions to observe the thought process - I was fascinated. But it was this surgery that Impressed upon me more than any other the surgeon's motto:
The Enemy of Good is Better
The case was tricky, and the surgeon had to take out more bone than he would've liked. When putting in the prosthesis, the fit wasn't exact, and we tried several combinations to find the one that would have the least likelihood of dislocation. When putting in the final pieces, the final cap wasn't perfectly parallel to the prosthesis like it was supposed to be and that screw we couldn't get flush with the mechanism, but the surgeon said "good enough"
Having been a surgical patient, I know the sound of that, the thought of that, is terrifying. I don't want it "good enough," I want it perfect! But so many surgeons have fallen prey to the thought that they can get something just a little better, and then wound up ruining the whole damn thing. Perhaps we could have gone back, re-drilled that hole and made the screw lie flush, or perhaps that would have caused the already weak bone to fracture. It wasn't worth the risk.
Surgery is one of those rare fields in medicine where you are physically confronted with your work and its flaws, and it can be hard to beat back that perfectionist urge that says "yeah it does the job, but I can do better," but for the sake of your patients, the enemy of good is better.
Sunday, December 11, 2011
Saturday, August 27, 2011
Chronic Pain Patients and Drug Seekers
I'm currently on my Internal Medicine rotation, and there is something I have been pondering recently:
Among the things you deal with when you work in a hospital are patients who are admitted for chronic conditions who are treated with opiates. Unfortunately, there are plenty of people out there who know how to manipulate the system - they know exactly what to say so they can get admitted and get their narcotics. There are also plenty of patients who have legitimate pain and really do need that help to control their pain but are quickly dismissed by most doctors as yet another drug seeker.
I admit that I am myself guilty of joking around with the medicine team about how a patient happens to be allergic to all analgesics except Dilaudid, or how a patient previously writhing in constant "10/10 pain" seems to be astonishingly well-recovered when he thinks no one is looking. I can understand the frustration of wasted time and resources when there are patients with serious diseases (that have actual treatments) around who need help.
However, a recent patient I had really got to me because of the way the doctors on our team treated her. Names and details have been changed for the sake of patient privacy.
I was supposed to pick up two new patients that morning off of our patient list, and "Helen" was the second one I selected. Her chief complaint listed was new onset upper extremity weakness, and since I hadn't had any neurology patients as of yet, I thought it would be an interesting case. I got to her room just as the neurology team was finishing up with her. I struck me that they seemed dismissive and in an awful hurry to get out of her room. Looking at her, she was extremely upset, looked like someone who hadn't slept in days (in fact she hadn't gotten any sleep in 5 days) and seemed desperate for someone to listen to her. So I did. She gave me her whole story of her illness - of how before this all started, she was moving up in a male-dominated industry and kicking ass at it, a loving husband and three young children. She loved her life and career, and then it all hit a brick wall. She started getting sharp, searing pains in her legs, and a multitude of neurological symptoms that came and went. She saw doctor after doctor, and as her condition progressed, she had to quit her job and wound up confined to her bed most days and requiring high doses of opiates to control her pain.
Eventually after nearly 10 years of searching, she managed to be directed to a doctor who recognized what she had, and was able to send her to a specialist who is world-renowned for treating her disorder. relieved to at least have a name for it and that she wasn't going to continue to be told that she was crazy or that her symptoms were caused by depression, she still faced the problem that her disease had no cure and that she still needed narcotics for her pain.
She presented to the emergency department in a flare-up of her pain in addition to the new loss of strength in her right arm, and was admitted to our service because neurology had refused to take her. She was in a lot of pain on admission and refused the arm MRI that neurology wanted to do because of the discomfort she was in. What astonished me was how quickly the residents (and even the attending) on my service started making fun of her - that she didn't want the MRI because she "knew" that they wouldn't find anything, that she "clearly" was faking it, and refusing to up the dose of her pain meds as asked us tearfully to do just so she could sleep. The junior resident on our team seemed to particularly fond of purposely antagonizing her.
It really pissed me off when the junior resident offhandedly remarked, as we readied to discharge her, that we should "just let her enjoy her new diagnosis". SERIOUSLY? This woman clearly wasn't "enjoying" anything, and even if she wasn't in as much pain as she said she was, she still deserves at least a modicum of respect.
She came to us for help and she was treated like crap. Perhaps I was taken in, and the fact that she reminded me so much of myself made me oversympathize with her. But I still feel that the way her case was managed did nothing to help her and was bad for us as clinicians. When someone has pain, you can't see or measure it, but that doesn't make it any less problematic than a symptom you CAN see and measure. Helen has watched her life completely fall apart, and my team took part in making her more miserable instead of less. Whether or not you feel she belongs in the hospital, the least we could have done is express some empathy, instead of just telling her we had no justification for keeping her and kicking her out.
Having been on the receiving end of a cold dismissal by a physician (even without the "drug seeker" label, I can imagine what Helen is feeling right now - hurt, rejected, alone. I can only hope that she continues to look for something, anything that will help and that physicians she encounters in the future care more than my team gave her.
Among the things you deal with when you work in a hospital are patients who are admitted for chronic conditions who are treated with opiates. Unfortunately, there are plenty of people out there who know how to manipulate the system - they know exactly what to say so they can get admitted and get their narcotics. There are also plenty of patients who have legitimate pain and really do need that help to control their pain but are quickly dismissed by most doctors as yet another drug seeker.
I admit that I am myself guilty of joking around with the medicine team about how a patient happens to be allergic to all analgesics except Dilaudid, or how a patient previously writhing in constant "10/10 pain" seems to be astonishingly well-recovered when he thinks no one is looking. I can understand the frustration of wasted time and resources when there are patients with serious diseases (that have actual treatments) around who need help.
However, a recent patient I had really got to me because of the way the doctors on our team treated her. Names and details have been changed for the sake of patient privacy.
I was supposed to pick up two new patients that morning off of our patient list, and "Helen" was the second one I selected. Her chief complaint listed was new onset upper extremity weakness, and since I hadn't had any neurology patients as of yet, I thought it would be an interesting case. I got to her room just as the neurology team was finishing up with her. I struck me that they seemed dismissive and in an awful hurry to get out of her room. Looking at her, she was extremely upset, looked like someone who hadn't slept in days (in fact she hadn't gotten any sleep in 5 days) and seemed desperate for someone to listen to her. So I did. She gave me her whole story of her illness - of how before this all started, she was moving up in a male-dominated industry and kicking ass at it, a loving husband and three young children. She loved her life and career, and then it all hit a brick wall. She started getting sharp, searing pains in her legs, and a multitude of neurological symptoms that came and went. She saw doctor after doctor, and as her condition progressed, she had to quit her job and wound up confined to her bed most days and requiring high doses of opiates to control her pain.
Eventually after nearly 10 years of searching, she managed to be directed to a doctor who recognized what she had, and was able to send her to a specialist who is world-renowned for treating her disorder. relieved to at least have a name for it and that she wasn't going to continue to be told that she was crazy or that her symptoms were caused by depression, she still faced the problem that her disease had no cure and that she still needed narcotics for her pain.
She presented to the emergency department in a flare-up of her pain in addition to the new loss of strength in her right arm, and was admitted to our service because neurology had refused to take her. She was in a lot of pain on admission and refused the arm MRI that neurology wanted to do because of the discomfort she was in. What astonished me was how quickly the residents (and even the attending) on my service started making fun of her - that she didn't want the MRI because she "knew" that they wouldn't find anything, that she "clearly" was faking it, and refusing to up the dose of her pain meds as asked us tearfully to do just so she could sleep. The junior resident on our team seemed to particularly fond of purposely antagonizing her.
It really pissed me off when the junior resident offhandedly remarked, as we readied to discharge her, that we should "just let her enjoy her new diagnosis". SERIOUSLY? This woman clearly wasn't "enjoying" anything, and even if she wasn't in as much pain as she said she was, she still deserves at least a modicum of respect.
She came to us for help and she was treated like crap. Perhaps I was taken in, and the fact that she reminded me so much of myself made me oversympathize with her. But I still feel that the way her case was managed did nothing to help her and was bad for us as clinicians. When someone has pain, you can't see or measure it, but that doesn't make it any less problematic than a symptom you CAN see and measure. Helen has watched her life completely fall apart, and my team took part in making her more miserable instead of less. Whether or not you feel she belongs in the hospital, the least we could have done is express some empathy, instead of just telling her we had no justification for keeping her and kicking her out.
Having been on the receiving end of a cold dismissal by a physician (even without the "drug seeker" label, I can imagine what Helen is feeling right now - hurt, rejected, alone. I can only hope that she continues to look for something, anything that will help and that physicians she encounters in the future care more than my team gave her.
Tuesday, July 5, 2011
DisOriented
Preparing for and taking Step1 was a surreal experience. 6 weeks was spent on my own schedule, and yet none of that time was my own. You know you're studying for step 1 when a day that you take a practice exam, do laundry and prepare food for the week is considered a relatively "unproductive" day. Most people will never really comprehend what it's like to have to study 8-12 hours per day. The misery is compounded by the fact that you need to do this EVERY day. Any breaks you take you feel guilty, and you think about what that time means in terms of points lost when you take the exam. What if you get a 187, and that one hour was all you needed for that one extra point in order to pass? Crazy thought, I know, but it goes through your mind each and every break.
I won't know my score for another few weeks, but I'm trying to not worry about something I no longer have any control over.
What I felt after the exam was by far the weirdest I've ever felt. Once I got into that pattern of studying all day every day, I suddenly had no idea what to do with myself and this new found concept of free time.
Today was the first day of orientation for my first ever clinical rotation. I'm starting with medicine, in hopes that still being fresh from Step 1 will be helpful, and that this will be a good base for the rest of the year. Last week was general orientation, which was mostly boring didactic sessions and introductions to databases and things that were almost immediately forgotten. Internal orientation this week looks like more of the same, except for friday where we're learning Advanced Cardiac Life Support, which may possibly be the only useful thing we do this week.
I won't know my score for another few weeks, but I'm trying to not worry about something I no longer have any control over.
What I felt after the exam was by far the weirdest I've ever felt. Once I got into that pattern of studying all day every day, I suddenly had no idea what to do with myself and this new found concept of free time.
Today was the first day of orientation for my first ever clinical rotation. I'm starting with medicine, in hopes that still being fresh from Step 1 will be helpful, and that this will be a good base for the rest of the year. Last week was general orientation, which was mostly boring didactic sessions and introductions to databases and things that were almost immediately forgotten. Internal orientation this week looks like more of the same, except for friday where we're learning Advanced Cardiac Life Support, which may possibly be the only useful thing we do this week.
Tuesday, March 29, 2011
I can do this
Looking at most of my previous posts, especially the most recent ones,I can see that they're very negative, depressing, self pitying,endless pit of despair, etc. I'm not going to take them down because they are true to how I felt at the time. I just feel that it's necessary to say that I don't feel like that all of the time. It's just that it is times like those that I most feel the need to get out all the things I feel I need to say but can't bring myself to say out loud.
Pain is scary. Chronic pain is a whole different animal. It has changed my life completely, and certainly not for the better. Friends and classmates frequently tell me "I don't think I could deal with that."
Honestly, I don't either, but when I say that, they often reply. "well you do, because you have to."
And that's the most difficult part. No breaks. No choice. I can deal with this day by day and I do. I'm still not sure how.
Weirdly enough, it reminds me of how people often respond when I tell them I'm a vegetarian - "Oh, I could never do that."
What am I supposed to say to that?
Honestly, I don't care if you're vegetarian or not. I do it for myself, not to show the world that I have the willpower to do so. Honestly, after the first year or so, it became easier to be vegetarian than it would to not be. I do it because it's part of who and what I am now and can't bring myself to be any different.
However easy the choice may be though, it is still entirely my choice.
The pain, obviously, is not my choice, but how I wish it were something I could give up, think through or past, and toss aside. It's kind of sick but I find myself wishing there were some kind of scan or test that my doctor wuld do that would finally come up positive
- Oh, you're vegetarian? Let me check your B12 levels.
- Hey, it all started with an infection, what if it's autoimmune - check out this antibody titer.
- Let's do this MRI with contrast, Oh here's a small tumor we missed.
(That's right, I found myself wishing for a tumor)
But at least that would mean there was something I could do.
ANSWERS.
TREATMENTS.
or even if there was no cure for whatever it was, having a real diagnosis would be so much more satisfying than being told it's some permutation of chronic headache syndrome.
Pain is scary. Chronic pain is a whole different animal. It has changed my life completely, and certainly not for the better. Friends and classmates frequently tell me "I don't think I could deal with that."
Honestly, I don't either, but when I say that, they often reply. "well you do, because you have to."
And that's the most difficult part. No breaks. No choice. I can deal with this day by day and I do. I'm still not sure how.
Weirdly enough, it reminds me of how people often respond when I tell them I'm a vegetarian - "Oh, I could never do that."
What am I supposed to say to that?
Honestly, I don't care if you're vegetarian or not. I do it for myself, not to show the world that I have the willpower to do so. Honestly, after the first year or so, it became easier to be vegetarian than it would to not be. I do it because it's part of who and what I am now and can't bring myself to be any different.
However easy the choice may be though, it is still entirely my choice.
The pain, obviously, is not my choice, but how I wish it were something I could give up, think through or past, and toss aside. It's kind of sick but I find myself wishing there were some kind of scan or test that my doctor wuld do that would finally come up positive
- Oh, you're vegetarian? Let me check your B12 levels.
- Hey, it all started with an infection, what if it's autoimmune - check out this antibody titer.
- Let's do this MRI with contrast, Oh here's a small tumor we missed.
(That's right, I found myself wishing for a tumor)
But at least that would mean there was something I could do.
ANSWERS.
TREATMENTS.
or even if there was no cure for whatever it was, having a real diagnosis would be so much more satisfying than being told it's some permutation of chronic headache syndrome.
Thursday, February 24, 2011
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAH!
I want to scream until I'm hoarse. I want to hit things until I bleed. And most of all I want to reach through my skull and pull out this THING that is eating its way through my brain.
When I say I hate my life, I am not exaggerating one iota. I am completely and utterly miserable and I see no way out and no way up. 3 years now, and there is absolutely no reason to believe I am ever going to be "better".
I am finding it really hard to accept that I have to be okay with not being okay.
I am a burden to my friends; i can't go places without having to leave early, being drugged up, or both.
I end up doing the bare minimum to get by because that is the maximum I am physically capable of doing. And I hate it. So much.
I feel utterly alone. I write this on an online blog that no one but me reads because there is no one I can say this out loud to without feeling guilty for putting this on them.
Some, like my mom, will give suggestions about drugs, herbs therapies, blah blah blah, because they feel sorry and want to help, but I can't take that any more. 3 fucking years I've had this and I've tried so many drugs, so many therapies, only to be disappointed. Every time, I get my hopes up that THIS TIME will be different. THIS TIME it will work. THIS doctor/therapist/other specialist knows what he/she is doing. Then, the next bad day I have, it practically kills me. The physical pain of that day is second only to the hurt of knowing that once again that I haven't found a cure or even an answer.
3 years and all I've got is a diagnosis of exclusion
3 years and I hate going to bed at night knowing that tomorrow will be more of the same.
Lately, i have not been able to make it a single day without having to stop what I'm doing and lie down.
I hate my life. I am miserable. never in my life have I wished so much that I could simply disappear.
I want to cease to exist.
I am not living my life, I am tolerating it.
When I say I hate my life, I am not exaggerating one iota. I am completely and utterly miserable and I see no way out and no way up. 3 years now, and there is absolutely no reason to believe I am ever going to be "better".
I am finding it really hard to accept that I have to be okay with not being okay.
I am a burden to my friends; i can't go places without having to leave early, being drugged up, or both.
I end up doing the bare minimum to get by because that is the maximum I am physically capable of doing. And I hate it. So much.
I feel utterly alone. I write this on an online blog that no one but me reads because there is no one I can say this out loud to without feeling guilty for putting this on them.
Some, like my mom, will give suggestions about drugs, herbs therapies, blah blah blah, because they feel sorry and want to help, but I can't take that any more. 3 fucking years I've had this and I've tried so many drugs, so many therapies, only to be disappointed. Every time, I get my hopes up that THIS TIME will be different. THIS TIME it will work. THIS doctor/therapist/other specialist knows what he/she is doing. Then, the next bad day I have, it practically kills me. The physical pain of that day is second only to the hurt of knowing that once again that I haven't found a cure or even an answer.
3 years and all I've got is a diagnosis of exclusion
3 years and I hate going to bed at night knowing that tomorrow will be more of the same.
Lately, i have not been able to make it a single day without having to stop what I'm doing and lie down.
I hate my life. I am miserable. never in my life have I wished so much that I could simply disappear.
I want to cease to exist.
I am not living my life, I am tolerating it.
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