Thursday, June 14, 2012
The Future is something which everyone reaches at the rate of sixtyminutes an hour, whatever he does, whoever he is. ~C.S. Lewis
Sunday, August 14, 2011
Often Wrong, Never in Doubt
In surgery we have a lot of sayings and mottoes: "The rules of surgery: 1. eat when you can 2. sleep when you 3. pee when you can and 4. don't mess with the pancreas", "Better lucky than good", "All bleeding stops eventually" "The enemy of good is better". My personal favorite is "Often wrong, never in doubt" and this was told to me when I was a first year med student and first exposed to the favorite surgical pastime: "pimping". It has a terrible name, and if you've never gone to medical school or don't work with surgeons, when you hear the phrase "pimping" you likely think of hookers and their employers. I assure you, surgical pimping has nothing to do with either. Being "pimped" means having one of your seniors, be it a resident or attending, ask you questions. This generally happens in the OR and will often pertain to the case, such as "what is this structure?" "what's the blood supply to this organ?" "what's the indication for this procedure?". It also occurs commonly during rounds and is generally considered an educational exercise. I can assure you, the questions I have gotten wrong over the years have been the answers that I have not forgotten. In my third year surgery rotation, there was a vascular surgeon that loved to teach, but in the form of pimping, meaning you would be assaulted with questions and scenarios until you finally said "Uncle!" aka "I don't know". He would then teach you about whatever it was for the next 20 minutes, it was great, but very intense. One day I was going to scrub with him on a temporal artery biopsy, so I studied everything about the anatomy, the indications, the complications, I thought I knew it all and could field any question he would throw at me. Well, as soon as we prepped and draped the patient and was about to inject lidocaine, the local anesthetic, he asks me, "what is the toxic dose of lidocaine and what is the first sign of its toxicity?'. Of course I had no idea, I should have been better prepared, knowing his penchant to ask about ANYTHING pertaining to the case, but I didn't know then. I do know now and I will never forget it.
That being said, one can imagine pimping can sometimes be a little malignant and a way of clearly establishing superiority, but rarely in my experience. Surgeons also tend to be people who like to know everything about things that interest them, fans of minutiae and trivia. I have been pimped on the difference between diamond carats and gold karats, what kind of plane is it in the last scene of Casablanca, how many surgeons have won the Nobel prize, etc. Obviously, not pertinent to the case or patient per se, but clearly of interest to the surgeon.
As I said, the first time I was pimped I was a first year medical student and shadowing my mentor who is a plastic surgeon. I was observing a facelift and he asked me to identify the thin muscle in the neck he was pointing to and tell him the innervation. I responded with a slight lilt in my voice, making my answer sound less like an answer and more like a question. He responded, "The most important thing you need to know about being a surgeon is that you may be wrong but you are never in doubt."
I luckily grew up with an excellent role model for this. My father is king of convincing you whatever he says is right, no matter how ridiculous it may sound and how much your mind may try and rebel his explanation. It's all in the delivery, and it will make you doubt whatever opposing knowledge you have, just ask my mom, she has been the victim of many less-than-fact explanations that she may have repeated trusting my dad's "knowledge". In order for this to work, you actually need to be quite intelligent and have a broad base of knowledge, so that the explanation provided will be assumed to based in fact. I, luckily inherited my dad's ability to confidently provide possibly false explanations on the fly, and clearly it serves me well in surgery. The best is when my father and I disagree on some "fact" and then it turns into an actual research expedition. In fact, everyone in my family has some form of this "disorder", so for a while we actually kept a record of these wagers and tallied who was right most often (I believe I won for the last recorded year, 2009, but then again, the record-keeper may have had some selection bias). So once again, my family has provided me with an incredible foundation for my surgical education.
Saturday, July 16, 2011
When Keepin' It Real Goes Wrong
I love the Chappelle Show and was beyond excited to find out that Dave Chappelle actually lives in SW Ohio, actually about 10 minutes away from me. he had a segment called "When Keepin' It Real Goes Wrong". YouTube it if you haven't seen it, but the theme of the segment was someone who misguidedly "kept it real" (i.e. had the wrong attitude in an inappropriate situation) and then suffered for it. I'd like to use this idea to highlight some of my more recent experiences.
My intention for this blog is not to be a place to rant or vent (I usually do enough of that at work), it is meant to be a place of mediation, entertainment and introspection. However, I'd like to consider this an educational post about how to treat your healthcare workers. Almost all of us went into medicine because we genuinely want to help people, as cliche as that sounds. We like to make people feel better, and most surgeons would argue, we like to cure your diseases. This is true for the nurses, the PAs and NPs, the techs, even the environmental crew. As sick as it sounds, we actually like hospitals and the idea that we get to participate in an important, if not critical part of the patient's life. That being said, there are times when we hate our patients, without question, and if it were even remotely ethical, we would either throw them out the door or muzzle them.
Trauma patients are a very special mix of patients. While there are the innocent people who had random badness happen to them, a large majority of our patients (particularly on the weekend or on payday) are made up of people who brought the badness on themselves. While the sober un-helmeted motorcycle crash is stupid, he isn't really hateful, he (hopefully) only hurt himself. The worst patients are the drunk and/or high douchebags (for lack of a better word) who decided to drive some sort of motor vehicle. Not only have they put their life in danger and are now our responsibility to save, but they can and do hurt and kill innocent people. Aside from this, they also usually come in abusive and combative. As doctors we have taken an oath to treat and heal all that are in need, but let me tell you, sometimes this is nearly impossible. Usually a little passive aggression helps you out, maybe pressing a little longer where the patient said it hurt, or letting the guy with the biggest hands in the room do the rectal instead of one of us gals with tiny fingers. It's nothing detrimental to the patient, but it gives you a little sense of reciprocity.
Sometimes passive aggression just doesn't cut it, and that's where a kind of verbal aggression sets in, at least for me. I can have a little bit of a sharp tongue and speak without a filter (I'm kinda working on tempering it, in my spare time), so when one of these patients comes across my path and "keeps it real", I'm a little more inclined to "keep it real" myself and orient them to the reality of the situation, meaning I am in part of the team that is in charge of what happens to them and they have zero control of the situation. I like to think of this as patient education, disabusing them of their delusions. Generally, once reality and/or sobriety sets in, they come around to our way of thinking. Of course, there are some people that are just assholes drunk or sober. But I'd like to illustrate this with two recent, favorite examples.
The first was a young man who was brought in with a stab wound to the groin by his girlfriend. One can only speculate what she was aiming for, but was a little lateral to it and could have possibly gotten his femoral artery, which is a pretty big artery. I had just finished a case in the OR (probably butt puss, the intern's usual case) and was asked to hold pressure on the stab site to try and keep the hematoma from expanding. There's a saying in surgery that there are a few places into which a patient can bleed out: the chest, the abdomen/pelvis, the thigh, and the floor. This patient was possibly at risk of exsanguinating into his thigh and my job was to prevent that while the second on-call attending and more OR staff made their way to the hospital, it was a trauma filled day and our on-call attending was already in the OR with another patient. The amount of pressure and the place in which I had to apply pressure was surely not very comfortable for the patient, it was painful for me as well on many levels. As I'm sure you could imagine, this young man was colorful, to be euphemistic. This was not the first time this girlfriend stabbed him, he had been shot and he had many scars from myriad scuffles with her. He would not stop complaining about how bad my pressure was hurting his leg and complaining about everything and then accusing me of enjoying hurting him. The nurses would try and come to my aid and say how i needed to apply that much pressure to help him, etc, we try and take care of each other. I let this go for about 20 minutes or so (maybe less) before I informed him in no uncertain terms that an injury to the femoral artery could cause a patient to bleed out completely in 6 seconds (his injury was nowhere near the caliber you would need for that, but it was a fact I thought was pertinent to share, I'm all for patient education) and that if my pressure was too much of a bother to him, I would happily remove my hand and let us see what happened, because pressing down on his groin was not exactly my idea of a good time either. Sometimes you just need to establish who is the alpha in the relationship. His eyes widened at this "education" and he quickly changed tune. The nurse chimed in and said something to the effect that he should be thanking me for saving his life and quit being nasty. From that point on, he was much more agreeable. In fact, I learned way too much about him and offered that he should reconsider his current relationship or at the very least have his girlfriend pursue anger management. He was at least entertaining for the duration of our time together after our orientation to reality. He walked out of the hospital fine the next day, I'm sure I'll see him again courtesy of his girlfriend.
The latest and greatest illustration of how not to treat your life-saving team came in the other night. He had a blood alcohol level that would leave most of us intubated or dead, but he went out driving, obviously without his seatbelt. I was at the head of the bed for this trauma. He came in bloodied and combative. While I was doing the primary survey, he decided he didn't like what we were doing: asking questions, listening to breath sounds, finding pulses, drawing labs, you know, generally working towards finding and fixing his injuries. When a patient is on the long-board and in a hard collar so they can't move their neck and head, especially with the bustle of the trauma bay, it can be hard to communicate with them, so often you have to lean over their face and speak loudly and clear. As I was doing this, the patient decided he had enough and decided to spit his bloody sputum at my face. Luckily, I had a face-mask and shield on, so it just hit the mask, but he did have a blood-borne communicable disease (which I found out later, and only incensed me more) and that's just bad form to spit at the people helping you. One of my awesome trauma nurses who was near me put a hand over his mouth and educated him that spitting blood at people was unacceptable. He proceeded to flail around, lifting his head and being uncooperative and all the while complaining that he couldn't breathe. I assured him that if he was speaking this much he could breath. He then decided that the hard-collar was to blame and wanted it off and assured us that it would be okay, he knew he was medically fine. At this point he had not only spit viral blood at my face, flailed around, cursed at all the staff and was generally unbearable, but more importantly, he was so intoxicated that he could have been doing serious, irreversible damage to himself by moving around and being uncooperative. If he had an unstable cervical spine fracture, he could have transected his spinal cord by moving his head all over. It was time for me to "keep it real". When he declared he knew he would be fine, I asked him if he had gone to medical school to which he replied, in colorful language, that he had not. I then informed him that those of us who had would be the ones making all of the decisions about his care and it was in his best interest to be cooperative. He eventually calmed down and had very few injuries. I decided to tag along for his post-op check and see if he was actually a decent human when sober. During our exam I asked if he had been out of bed (one of surgery's favorite activities for our patients), and he said no because he felt so bad. I inquired as to what felt bad and he said he felt awful about what he did. I took this as a perfect time for "patient education". I told him that was appropriate, he was lucky, he could have hurt himself worse and others, but also that he was incredibly uncooperative and abusive to the staff that was trying to save his life that night. He apologized and actually genuinely seemed repentant. I'm not optimistic about my odds of not seeing him again as a trauma, but hopefully he'll be less hateful to the staff next time.
In summation, while we, the medical staff, can sometimes seemingly be a little insensitive to our patients because it's easy to forget that our normal day is the worst day of our patient's life (I'm sure I'll post on that at some point), we actually care about our patients, no matter how abusive. What it essentially boils down to is the "golden rule", treat others as you wish to be treated. No one gets an award for being the most stoic, most abusive or most uncooperative patient, just like no one gets an award for being most aggressive doctor, sassiest nurse or most dismissive. I happen to be biased towards the hospital workers because, honestly, not a single one of us would opt to spend Saturday night dealing with drunk patients instead of being out with our friends having fun, but this is the life we chose and, honestly few of us would give it up. I'm just saying, be cognizant of your attitude in situations and make sure that it's appropriate, in the hospital and out. Don't let "keeping it real go wrong".
Sunday, July 10, 2011
Trauma-rama
I only have 8 nights left on trauma nights, before I start my month of trauma days. I am being traumatized early on and then won't see it again all year. I'm actually quite sad about leaving trauma nights. Yes, it is exhausting when Ohioans decide to celebrate America's independence by stabbing each other all night long, and the lack of a helmet law in Ohio is troubling at best, lethal at worst and mostly, keeping vampire hours is weird. I report to work between 6 and 6:30 PM, we sign out for about 45 minutes (usually screwed by the seemingly scheduled "sign-out trauma alert") and work until 6 AM when we sign out until about 7AM. Mondays we have Morbidity and Mortality conference from 7-8 AM and Thursdays we have Trauma conference from 6:45-8:30ish AM (expect a future post on the value of M&M conferences). So basically, I am a transient in my house. I have one day off a week, Tuesday nights, which, when you're on nights, kinda screws with your rhythm. You end up trying to stay up all night with nothing to do, just so you don't revert to normal human hours, but usually fail and end up sleeping through the night. At this point, I anticipate unpacking sometime around the end of my second year, maybe third year.
But it's seriously awesome. A large part of it is the incredible people I work with. I love my chief resident (kinda like the VP of the service) who is a PGY4 (post-graduate year 4, meaning he graduated med school 4 years ago and has 1 year to go). He wants me to be involved, he sends me to the OR whenever appropriate and is exceedingly patient when I am very hesitantly dissecting appendices laparoscopically, offering very subtle advice such as, "you might want to actually grab that [piece of inconsequential schmutz that's obstructing our view of the appendix] and just kind of pull it down and out of the way". It is very kind because I'm sure everyone in the OR is thinking "Please stop letting the intern do cases, we all want to get out of here sometime today" (luckily what I lack in speed of dissection I try to make up for in being otherwise helpful, such as moving the stretcher out of OR and just being generally nice). He is also super-smart, doesn't mind my auto-default to diagnosis of malingering or my tendency to double-check stupid orders with him, like "um, can this patient with a fever have tylenol?"
I also have the exquisite pleasure of having some of the most hilarious, bad-ass women trauma physician assistants on with me at nights. Jamie, Leanna, Pattie, and Megan are some seriously funny ladies who know how to handle just about anything that comes their way, and it all does. Their phone is the one that is always ringing and they all seem to know exactly what is going on with every patient on our list. It's pretty amazing, I am in awe and have much to learn from them. Rounding out the team is a third-year ER resident who is awesome, she is super-smart, happy to teach, and coined the term "Gummicolith" which is the obstructive structure that the trauma night team will all eventually have jam in their appendices and cause acute appendicitis due to our excessive consumption of gummy candy eaten between the hours of 3-7am. They also have incredible senses of humor, are incredibly warm and actually more fun to be around than most people, so it makes coming to work kinda like hanging out with friends.
We are a level 1 trauma center, which, from my understanding, means something different in every state, but boils down to the ability of the hospital to handle catastrophes. For us that means that we have a dedicated trauma team, an in-house trauma surgeon, a CT scanner that we have access to as soon as we deem it necessary, ORs and OR staff to do cases at any time of day and a helipad to helicopter patients in. I did my surgery clerkship at a level 1 trauma center in Brooklyn, so I am not unfamiliar with the "running of a trauma", but I have to say, we do it a little better here in Ohio, probably because the volume is pretty ridiculous. Usually it goes like this: we get a page to our trauma pagers (yes, I carry multiple pagers and phones, it's awesome being able to be found so easily) alerting us to a trauma that's coming in, the category of trauma, the ETA and hopefully a little something about the mechanism. Category 1 means badness: penetrating trauma, arresting patient, unstable vital signs, etc. It also means the attending will be present at the arrival of the patient. A category 2 is still not a smiling rainbow of a patient, but they are usually pretty stable, just banged up, a usual example is a little old man or lady on a blood thinner that fell/hit their head/restrained driver, etc. When it's around 5 minutes to the ETA we all gather in the trauma bay put on lead aprons (so we can take X-rays while doing secondary survey, without having everyone step out of the room), gowns, gloves, masks. We have our gear ready: trauma shears to cut off clothing instantly and stethoscopes. The members of the team include our surgical team, the trauma nurse who somehow manages to ascertain and filter all the important info that is being shouted out and records it on the trauma flow sheet. We have respiratory therapy there in case the person comes in intubated or will need to be, x-ray techs to do our immediate chest and pelvic x-rays (if needed), lab techs to draw trauma labs and a kind of circulating nurse to help with everything else. So, everyone knows their job and there is a kind of organized chaos that probably looks like a cluster from the outside, but is actually quite controlled.
Being a resident at a level 1 trauma center requires you to be certified in Advanced Trauma Life Support (ATLS), which is like CPR on crack. You need to know how to stabilize just about any patient with minimal resources. I believe my final practical exam was a patient ejected from a car, who was 32 weeks pregnant with a pelvic fracture, tension pneumothorax, open femur fracture and hypotension. It's really easy to sit in a lecture hall and read the algorithms of ABCDEs of trauma (Airway, Breathing, Circulation, Disability/Deficits and Exposure)and think, "no problem, I can totally do this", but when you are standing there in a simulation, your mind goes in a million directions and your begin to triage your own thoughts or it goes completely blank. Needless to say, I was terrified of starting out as the intern on the trauma night team, in the summer (which is the season for trauma) at a level 1 trauma center that sees incredible volume.
Starting my surgical training on the trauma/emergency general surgery service was absolutely terrifying, but just about greatest lesson ever. I don't think I have ever been so petrified in my life as when I was told to "take the head of the bed" for the first time. "Taking the head of the bed" means running the trauma. You are the one that declares the airway clear (or not), assesses breathing, circulation and basically are the commander of the room. Yes, lots of other people are around and checking these things as well, but your assessment is considered accurate unless proven otherwise. Yes, it's easy to assess airway when the patient comes in talking and can answer your questions, but what about the deaf mute that comes in from a car accident? (that took lots of creativity and many drawings and pointing to "yes" and "no" on a paper). Can you really hear clear breath sounds over the commotion of the trauma bay? What if you think you do, but the chest x-ray shows a tension pneumothorax? No intern wants to be a 007 (licensed to kill), especially not in the first week. The thing I have noticed most in these past few weeks is how easy it was to armchair quarterback as a medical student, when you had no real responsibility. I remember sitting in M&Ms or listening to plans on rounds and thinking, "I would have done that better, I would have thought of that sooner, etc". And yes, presented with a whole picture it's easy to see what's what. When you're in it and information is trickling in, the picture becomes less Mondrian (all clear lines and boundaries) and a lot more Seurat (lots of tiny dots of color that only make a clear picture when you stand far away from it). I'm finding that the hard lessons we learn in our surgical training really applies to a much larger demographic, if not everyone. On trauma, the whole story is usually unknown and the injuries are very rarely clear cut. Sometimes you just have to take what information you have, be guided by the best intentions and do what you think is right at that time given that information. Knowing this, I think we need to allow others to do that without judgement outside the trauma bay. We all armchair quarterback other people's lives and decisions, not necessarily from a mean place, but judgement is a natural reaction. I think if we are just a little more gentle with each other, knowing that sometimes a person makes the decisions they do with limited information and the best intentions, will allow us all to be more gentle with ourselves and I think we will find ourselves carrying lighter loads on our shoulders and having less regret in the long run.
Saturday, July 9, 2011
Dichotomy
Dichotomy has always been one of my favorite words. Probably because it has been present and celebrated in my life for as long as I can recall. I learned the word when I was 12 and I have used it almost as much as my other favorite descriptor: malingerer. My parents are black belts in like a million and a half styles of martial arts (our garage is actually a dojo and there was an interesting ER visit back in the day when my parents were sword fighting with katanas and my mom nicked my dad on his forearm and he said he cut himself cooking). My mother also practices traditional Chinese medicine, add the Korean siblings and we are are very much an Eastern-Western family. One of the mainstays of Eastern philosophies is the symbol of the yin-yang. While often the image of many misguided tattoos, it holds the truth about the dichotomy of life.
There is a balance between dark and light, masculine and feminine and within each lies a little of the opposite. I believe this is true of all of us. In my life I have been both the only biologic child as well as the lower middle child, I am a trained fine artist and a surgeon-to-be (a woman of both art and science). I believe in the science of the universe and evolution though I believe there are things we will never explain scientifically and those are the spaces in which God resides.
I am also, clearly, a fan of quotes. This Picasso quote seemed exquisitely appropriate. I try to spend what little free time I have (usually my drive home in the morning) debriefing and processing the events of my night. On trauma nights you have the fortune/misfortune of treating patients that run the gamut from innocent pedestrian struck by car to drunk, high unhelmeted motorcycle driver who ran into a car. We are bound by oath to care for each of them to the best of our ability, even though it can be hard when a drunk guy who just hit a car with an innocent family comes in combative and curses at you for trying to save his life.
Unfortunately I had what I consider the starkest illustration of life's dichotomy the other night. We had a bunch of add-on cases for the OR (meaning cases that would be done as rooms became available throughout the night), mostly lap gall bladders and lap appendices. After one of the lap appys, my pager goes off that reads a trauma alert for a category 1 trauma (the most dire) with a young girl who was hit by a car and was in full arrest. We all run to the trauma bay, get set up for CareFlight (our paramedic helicopter service) to bring her in. All of our hearts sank because we knew that she would likely be dead on arrival and our worst fears were confirmed by EKG and echo of her heart. A few hours ago, she was sitting on the curb watching fireworks, then some driver jumped the curb and drove off. This was a little girl who took the care to paint each of her toenails a different color. I said a prayer for her, and allowed myself to privately mourn the loss of someone who never got to really experience much of life. I prayed that her last moments were filled with awe of beautiful bursts of fireworks and not everything that came after. Immediately following this I was due in the OR to do an incision and drainage of a peri-anal abscess, or as we like to call it butt puss. These patients are usual poorly controlled diabetics or drug users who miss their veins or are "skin-poppers". At the time it didn't register how disparate these two situations were, I just knew I had more work to do and I was expected to seamlessly ease into one from the other. On my drive home it registered how bizarre my job is. I mean, cutting people open to "fix" them is bizarre enough (and I have a great post planned about the surgical personality), but going from such profound sadness to an illness that a person brought on themself by having little regard for their own life really struck me. My psychiatric colleagues would probably diagnose all of us with some form of dissociative disorder, because you can't perform without it. I like to think we just have found a way to master the dichotomy that lies within. Perhaps it is another space in which God resides.
Tuesday, July 5, 2011
What Matters Most is How Well You Walk Through the Fire
This is the true story of 1 NY/NJ raised surgical intern, picked to live in Ohio and learn to operate, be a real doctor, have a balanced life and stay connected with my wonderfully insane family and friends.
I figured I would pay homage to the first reality television show (The Real World, for those youngsters out there) that birthed the very questionable reality TV fare we have available nowadays. Because much like the way watching the Real Housewives of NJ makes you feel a whole lot better about your family and their craziness, my job makes me think my life outside the hospital is so normal it borders on banality.
As a little introduction, I am the lower middle child in a wonderfully interesting family made up of 2 caucasian parents, 3 adopted Korean children and me, the biological one, thrown in the middle (number 3 of 4). My oldest brother, Danny, found a wonderful woman who would not only up with us, but actually legally bound herself to the Ferrauiola family, Janet. They just had the most adorable little boy named Duncan, who is the love of my life and the cutest f-ing kid on the planet. Aside from my awesomely crazy family, I made the jump from fashion to medicine about 6 years ago, I'll tell you the whole story at some point.
Right now I have landed in Dayton, Ohio for my 5 year general surgery residency. I'm loving the program, my experience thus far and the people, though being far away from all my family and friends is painful at best and brutally lonely at worst. My good friend who is doing his surgery residency in Connecticut has a blog and I figured I would copy his idea, because honestly, you cannot make this stuff up. I have the unique pleasure of starting on the trauma night team at a level 1 trauma center. My hours are 6pm-7am 6 nights a week. The team was made up of me (a newly birthed doctor), a 4th year resident and a PA who may or may not leave at 3am until God smiled on us and gave us a wonderful 3rd year ER resident this past weekend, so now there are 4 of us to take care of the seemingly 1,000 patients we are taking care of in some form on the floors and all the traumas that come in over night. Not exactly the easing in to doctorhood I had hoped for. These will be my musings from "the field" peppered with fun Ferrauiola family stories.
I also chose the Charles Bukowski quote for this post because I find it to be the mantra I utter most often to myself. We all can prepare and think we know what to expect and how to handle any number of things that come our way, but when it comes down to it, no matter what you know, who you know, or what you can do, "what matters most is how well you walk through the fire".
*PS: all patient stories will be in line with HIPAA rules and regulations, I'm not trying to get my butt or my program's butt fined.
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