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maybe there’s a reason

So I have been thinking about how long it has been since I posted an entry to this blog.  (It really has been a while).  I thought back to my experiences over the last few months, things that I could have shared, and  almost everyone of them was a painful experience.  As I write this, I am sort of smirking, because by pain I’m referring mostly to the typical bullshit one hears about in regards to residency.   I didn’t really believe it would happen to me–I thought it was mostly stuff you see on TV–but it happens.  At the time, it kind of sucks and sort of feels like a punch to the gut when unprepared, but in hindsight it’s kind of funny. 

I was discussing with a co-intern of mine some of the things we learned this year and our mutually agreed upon top lesson learned was how to take abuse.  Again, I’m chuckling while I write this, but it really is true.  Don’t get me wrong, we did learn A LOT of medicine and number two on the list is how comfortable we all feel taking care of patients on the floor.  But, number one is definitely how to take abuse. 

In some ways, you have to train at it.   Taking abuse that is.  And that’s what part of this year is for I guess.  There’s always the possibility for getting chewed out.  Every day, there are at least 50 things that I do, which could earn me a major chew-out.  Not through any irresponsibility, not through any laziness, not for lack of caring, not stupidity but just because.  There is so much shit to sift through–all simultaneously–that you’re bound to get caught up on something.  Take for example the time I was presenting a newly admitted patient and I quoted some findings from a previous discharge summary dictated by a random attending who was not part of our team.  This attending just happened to be sitting within earshot, and screamed at me–interrupting our AM rounds–that the details of my presentation were totally wrong, that all interns are lazy, that I’m lazy, that I didn’t do any work, that I didn’t read his notes, etc.  Now, what he was yelling at me for being wrong about was stuff that I took directly out of his notes.  Makes no sense right?  No sense at all. 

So all at the same time, I was dealing with a random chew out, dealing with the embarassment of getting chewed out in front of my team and on top of that, dealing with an attending who was yelling at me for not doing what I actually did do.  All of this on total sleep deprivation and you about lose your mind.  I remember just standing there trying to make sense of it all, and just saying “yes sir, yes sir, yes sir” (always a safe response) until I figured out what had just happened.  Except by the time I realized that I was just nailed for no reason, everything was over.  In hindsight, there was nothing that would have been worth doing at that time except for saying “yes sir”.  This guy was a complete ass who was having a bad day and had his facts mixed up, which he took out on me.  Fair?  No.  Normal?  Kind of. 

These days, I take that stuff with a little more grace.  I still keep my mouth shut and absorb it but I don’t get flustered and I keep my poker face on.  What else can you do?  I’ve seen so many different permutations of being treated like shit that I’ve been there, done that for most of my intern-related chew outs these days. 

I know that I still know there’s a world of shit out there just waiting for me.   But I’m up to it.  I think.

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dusting this thing off

Wow, it’s been a long time since I’ve done this.  (I hope this works).

As some of you know, I’ve been in the midst of intern year of my residency.  At some point in the winter, I backed off on the blog.  Too little “me” time.  Working as many hours as I had been (officially 80 hrs per week), there was little time to get any of my personal business done, let alone blog on a consistent basis.  But, I’m gonna try to get back into this.

Let’s try, shall we? 

More to come soon…  !

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an observation

Why is it that when I wear my white doctor’s coat, people call me sir but when I’m wearing jeans and sweatshirt people ask me for an ID when I pay by credit card? 

Hmmm….

Although these days I’m not so sure that my white coat even has much power left.  Maybe it’s all the dirt and nastiness on it. 

You may have heard about the “white coat effect”–that patients tense up around physicians (e.g. in the doctor’s office) and their vital signs, like blood pressure, may be on the high side.  The last few times I’ve been in clinic and manually taken blood pressure on my patients, their pressures are just fine.  So either I have a calming effect or my patients aren’t taking me seriously.  My money is on the latter.

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a million stories

  Have you ever walked down a hospital corridor and looked around?  I mean really look around?  Noticed the scratches, dents and marks on the walls?  The hospital is filled with a million stories.  We turn around patients all the time–people coming and going–but their visits often leave their marks on the hospital.  I’m not trying to be touchy feely or anything, I’m talking about mostly inconsequential marks but reminders to all of us that the craziness existed long before us and will continue long thereafter.  Each mark, dent or scratch, a patient in hospital bed being pushed to a stat CT scan, to the OR, to interventional radiology.  Residents who’ve banged equipment into the walls while trying to get a last minute procedure done before leaving for the night.  Food services employees who run that damned gigantic food tray transport unit into every fucking thing, including my foot.

  Time moves quickly.  I’ve been going through the drill for about 4-5 months now and I’m sometimes so focused on surviving that it is easy to forget how many stories–interesting, tragic, or even annoying–happen everyday, for like a hundred years and to go on for even longer. 

  Makes me feel like a pimple on the ass of this hospital.  I’ll come and go.  Many came before and many will come after.  And maybe, just maybe, I’ll manage to turn into an abscess that needs to get drained and those who come after me will look at my scar and wonder what pain in the ass did that.

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here comes more trouble

  Clinic.  The worst.  Writing H&Ps even worse.  New admits at two minutes before my shift is over–a dagger in my eye.  But the pain is sometimes happily abated when you get a fairly straightforward (from the standpoint of medical history) patient with few medical co-morbidities. 

  Then I look down at the chart or an old note and see “end stage renal disease (ESRD)” and I know I’m screwed.  These patients are almost always quite sick with a lot of medical problems.  The reason is that people don’t typically lose their kidneys for no apparent reason.  And to lose significant kidney function usually requires a lot damage–in other words, a lot of chronic systemic diseases.  This usually means hypertension or diabetes.  Not so fast there because long term hypertension and diabetes cause a whole host of problems from heart disease, cerebrovascular disease and peripheral vascular disease in general–all of which make medical management much more painful.  Pain pain pain pain. 

  A patient that should be nicely and quickly tucked in becomes the dude you spend all night figuring out what to do with and then you are worrying about every second until you get your eyes on him again no matter how carefully you manage him. 

  Bottom line: don’t these people know that I need a break??!?!!?!?  Why do they have to be so sick?  ;-)

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at least i’m still a mudphudder

  I’m tired.  I’m beat down.  Some days I’m just like, I don’t know.  Some days I don’t know if I’m gonna make it through.  I mean, I’m like 4 months in now, which is good, but there’s at least another 8 months left and that’s just internship.   Whatever, at least I’ll always have my pieces of paper.  The ones that say MD and PhD on them.  They may not help me much when I’m the “Welcome to Walmart” guy, but at least I’ll still have them. 

  Welcome-to-walmart-guy, M.D., Ph.D.

  That’s funny.  I’m going to bed now.

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choosing poorly

Mudphudder before graduate school

Mudphudder before graduate school

I’ve made out pretty well for myself but I am constantly reminded of choices that I could have made better.  Much better.

 

Examples: (have I complained about this stuff before?) an acquaintance for scored 3 articles in the C/N/S journals all in the same week.  If you added the impact factors of all of the journals I’ve published in (double digits), it wouldn’t come close to the impact factor of one of those journals.  Former co-graduate students who formed “alliances” with each other and now they all appear on all of each other’s papers.  I look at the author lines on those papers and I see 12 names but know that only 3 people did 99% of the work.  Bullshit.  Yeah yeah I know that those papers are just meaningless filler on the C.V. but when you have your work too, a few extra lines doesn’t hurt.  Bullshit.  I won’t even get into the social structure around the alliances in our old lab.  But it was there and now all of those wankers end up with like 10 extra papers for nothing.  Maybe I should’ve hung out with them more often. 

Mudphudder when he looks up old labmates on pubmed

Mudphudder after he looks up old labmates on pubmed

 

 

Sigh, I definitely could’ve made better choices.

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romanticizing me

Well not me but, rather, health care workers in general. 

God, this looks like a retarded show.

God, this looks like a retarded show.

Has anyone else noticed a recent slew of medical tv shows coming out?  So far I’ve noted several new tv shows about nurses and at least one about EMTs.  All (at least from the commercials) greatly romanticizing the roles of each group–here’s a line from a commercial for a TV show about EMTs called “Trauma”: “when everyone runs away from a disaster, they run towards it”.  Ahahahahahahahahahahahaha!!!!  Most of them are too out of shape to “run” towards a disaster.  AHAHAHAHAHAHAHAHAHA!!!!  I’ve met some pretty good and knowledgeable EMTs but I’ve met some really bumbling ones too.  My favorite was the one who walked out of the ED with an apple jammed in his mouth and the location of the chest pain patient’s EKG rhythm strip unknown (probably in his back pocket). 

I don’t remember any lines from the shows about nurses but I do remember a lot of nurses yelling at the

AHAHAHAHAHAHAHA!!!!

AHAHAHAHAHAHAHA!!!!

actors who are supposed to be the doctors.  Maybe I remember that because it hit so close to home.  I’m pretty sure that for TV viewers, like for me, watching nurses annoy the shit out of doctors will get old FAST.  I mean, how many different ways can the writers come up with for whining and complaining, interspersed with pages to the overtired, overworked resident at 3am that says: “FYI: pt XYZ’s BP- 120/70, HR- 76, T-98.6″.  IS THAT WHAT YOU WOKE ME UP FOR????  Arrrrggggghhhhh!!!!!!  (note those are all normal vital signs). 

The shows on TV about doctors are just as bad AND we’re portrayed as a bunch of bumbling malcontents (which, to be fair, may not be that far from the truth).  Sometimes I actually think the reality TV shows about doctors are the best because you get to see the real life dysfunction. 

Okay, let’s hold it for a second.  If it came across that way, my intention is not to hate on anyone.  Nurses, EMTs and doctors–there is a gradation of quality terrible to really great as well as a gradation in their aproach to work from just a job to a calling.  There’s nothing romantic about it.  In fact, the same person can be superstar or dud depending on the day of the week.  Take me for instance, there are days when I hate life and the rotation I’m on and then there are days when I’m a freakin’ inspired doctor.  Very much like the dude at your local footlocker who sometimes hates life because he sells shoes for a living but then sometimes takes the approach that his job is important because he helps people find comfortable shoes.  Whatever.  Most of the time I would think that medicine is not that interesting to the lay person.  Hell, I wouldn’t want to watch most of what I do on TV.   Fillng out paperwork, fighting with everyone from other doctors to phlebotomy to the freakin’ CT scan techs in order to get something done.  It’s usually the end product of a lot of uninteresting stuff that is cool–a patient who is healthier.  Note that I didn’t even say cured because there is very little that actually gets cured.  Does that sound interesting, dramatic or romantic to you?

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right of passage

  Is it some kind of bullshit right of passage that everyone who enters residency/internship is supposed to break down and cry at some point? I don’t know if it’s just the feeling that comes with having to get used to a really difficult

This is residency incarnated and he wants to kick my ass.

This is residency incarnated and he wants to kick my ass.

lifestyle/job but sometimes it feels like that. There are days when I feel like there are older residents even nurses who have that look on their faces of “is this the day that he cracks”?  And mostly it feels like people are looking on in eager anticipation rather than in empathy.  I’m not saying that anyone purposefully does anything with the intention of causing one to cry (mostly at least–going through the process of residency has definitely fucked up a few people in the head).  But I’ve definitely gotten the evil smile. That would be the one I get in response to the look of abject terror when after AM rounds I look down at my census of 40 really sick patients each with a bunch of empty boxes next to their name that need to get checked off.
  I’ve come to the realization I’m living in a Rocky movie. (Note that whenever I need to find an explanation for the seemingly inexplicable, I turn to the universal wisdom of Rocky). In my version, residency is like Ivan Drago, where he stares Rocky down and he’s like, “I must break you”.  In fact, Ivan Drago says like 6 things in the course of that movie:

  • “You will lose.”
  • “I cannot be defeated” “I defeat all man.” 
  • “If he dies, he dies.”
  • “I must break you.”
  • “To the end.”

 All of which suggests to me that residency is willing to go the distance and has only the singular goal of crushing me.  At least in my version, I’m Rocky.  Then again, Rocky did lose like half of the fights in his movies…

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here comes trouble

  This isn’t meant to be an educational post about fibromyalgia but for those of you who aren’t familiar, here’s the brief wikipedia explanation:

 Fibromyalgia, meaning muscle and connective tissue pain (also referred to as FM or FMS), is a medically unexplained syndrome characterized by chronic widespread pain and a heightened and painful response to pressure (allodynia). Other core symptoms are debilitating fatigue, sleep disturbance, and joint stiffness. Some patients may also report difficulty with swallowing, bowel and bladder abnormalities, numbness and tingling (paresthesia), and cognitive dysfunction.  Many patients diagnosed with fibromyalgia also have psychiatric disorders.  Because fibromyalgia involves more than just pain, the term “fibromyalgia syndrome” is often used; not all affected persons experience all associated symptoms.

Also, nor is this post meant to bash fibromyalgia.  However, if the disease process isn’t clear to you or you’re confused, then you’re starting to catch on.  Clinically, fibromyalgia is diagnosed with the following criteria (from the Mayo Clinic):fibromyalgia-pressure-points

  •  
    • Widespread pain lasting at least three months
    • At least 11 positive tender points — out of a total possible of 18

Seems kinda wierd to me.  But that’s probably the just the fear of the scientifically unknown coming out in me.  I’m not trying to be sarcastic either.  I believe that there is probably some pathophysiologic process underlying fibromyalgia but who the hell knows.  These patients are definitely experiencing “pain” but what is the source of that pain?  Is there even a tangible source?  When you think about it, pain is really just our subjective interpretation of noxious stimuli.  You can have noxious stimuli without pain (e.g. with anesthetic), and you can have pain without noxious stimuli (called allodynia). 

  I gotta be honest here, after all that I still don’t know what the hell this disease is.  I mean, I’ve been in constant pain since July and my whole body aches but I’m pretty sure that’s from getting my ass kicked on a near-daily basis and not fibromyalgia.   But I digress. 

  Anyway, is it just me or are most of these fibromyalgia patients a little weird?   (Losing readership losing readership… AHAHAHAHAHAHAHAHAHAHA)  NOTE: I did not say ALL–just most of these patients.  I don’t know if there’s some pathophysiologic connection between the cause of pain in these patients and weirdness (I mean like borderline schizotypal weird and not ”enjoys lobster-flavored ice cream” weird), but there you have it.  My personal “N” for seeing these patients is small but I’ve heard it from a lot of other physicians too.  Probably insensitive pricks like myself.  But to be fair, I don’t know if it’s on the patient or if it’s on the doctors.  Most of these patients’ doctors I think get so frustrated with their non-specific and recalcitrant symptoms that they end up putting these patients on so much pain killer and anxiolytics that it would be hard not to be nuts.  Actually, now that I think about it, everyone I’ve seen with fibromyalgia has been on a shit-load of meds so this could very well explain it. 

  Probably a little of both.  But find out for yourself.

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the post-call hangover

Post call.  The day after your night of being on-call at the hospital.  You usually get out early (anywhere between 8am and 12pm in my experience so far) and then you go home and sleep. 

When I get home, I’m usually okay.  I’m wired from being awake for that long and I’m usually hungry so I’ll get something to eat.  I’ll get home and plop down on my couch, unwind with a little tv.  Usually it’s just the notion that I need to sleep that makes me go to bed rather than passing out.  That’s a little weird but I think I get pretty wired when I’m on overnight call.  Anyway, as soon as my head hits the pillow that’s when I realize how tired I am.  And then I’ll sleep for 3-5 hours before I’ll get up and take care of a few errands with the remaining hours in the day. 

Damn.

Damn.

This is when the hangover hits you hard.  After the post-call nap or snooze.  You’re tired but you know you have to get up and do something.  Errands, go to the gym, goof off, whatever.  But you have to take advantage of being home early.  You’re a little anorexic from your internal clock getting thrown off and food doesn’t taste quite as good.  You’re just–off.  But for me, the most troubling part of the post-call hangover is what I call donkey dick breath.  It’s a bit of a misnomer in that it’s not really my breath but more a nasty taste in my mouth.  As though during the period that I was asleep, there was a donkey dick in my mouth the whole time.  (I will stipulate at this point that I don’t actually know what a donkey dick tastes like but I would imagine that it tastes something like this.)  Anyway, I’m not sure where the donkey dick breath comes from because I brush my teeth before and after sleeping and strangely it only happens after my post-call naps (or short naps after geing awake for a long time).  Someone has to know what I’m talking about.   It usually takes all day to shake.  I’m post call now and I’m still trying to shake it.  Yuck.   

So I write this post for two reasons.  1) To see if anyone has any advice regarding the donkey dick breath.  2) To empower others who also suffer from post-call donkey dick breath.  You are not alone.

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residency interviews…

…Suck.  Easily one of the most painful periods of the last few years for me. 

  And, I just realized it’s that time of the year!  Yay!!!!!

  I think I wrote a number of posts about residency interviews last year, so if there are any interviewees interested in reading those, just search for “residency interviews” on the blog.  Otherwise, I will go on. 

  I have the benefit now of 4 months of internship under my belt to color my recollection of residency interviews.  I was pretty stressed out about them all.  And to some extent, rightfully so, I guess.  Internship is tough and you want to make sure you end up with good people.  Note I didn’t say good place.  I am on survival mode right now.  I hardly have time to give a shit where I’m at for residency.  What keeps me going and what I do think about (because it’s right up in my face) is who I’m working with.  I have to say that I’m with a great bunch of interns and I’m really happy for that.  My senior residents are also for the most part really awesome.  I think no matter where you go, you will find senior residents that have just been totally fucked up by the process of residency (perhaps I’ll turn into one of those people in a few years… or months).  But it makes life so much nicer when your seniors are awesome. 

  I think I’ve gained new appreciation for the importance of who your coworkers are.  I really didn’t give it any thought in medical school or graduate school.  Not sure why exactly.  I think medical school and graduate school are more solitary endeavors.  Plus, there’s never a question of “am I gonna make it past today?”, which happens on an almost daily basis for me now.  Having the support of good people is key.  On that day when you don’t know if it’ll all get done and you’re sure you’re gonna be there for 3 days straight, the last thing you want is some ass who is gonna pile more shit on you.  I’ve lucked out in that I haven’t had this happen to me (yet) but the thought has often crossed my mind and it makes me shiver.

  During my residency interviews, I didn’t pay so much attention to that.  At least, it wasn’t high on my priority list.  I will say though that when I interviewed where I’m at, I remember thinking to myself that I could really hang out and get along with these residents.  So I guess it played into my decision making but not as much as it probably should have. 

  So there you have, after all the glam and glitz of where you’re going for residency, you won’t even have the time to remember it.  Think about that.

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while we’re on the topic of genitals…

  All I can say is, FRRREEEEEEEEDDDDDOOMMMMMM!!!!!!!!

  I recently finished a rotation after which I will never ever, ever ever, ever ever ever ever have to do another pelvic exam ever again.  For as long as I live.  Ever.  Never. Ever again. 

  Never ever.  Ever.

  I’m quite pleased with that fact.  No offense to the ladies, of course.  There are plenty of unpleasant physical exams (for both doctor and patient), including the male prostate exam.  This is all bourne out of my own ignorance with the pelvic physical exam. 

  Really it all comes down to the fact that I get really uncomfortable when I have to do something for a patient that I really don’t know how to do–much less to do with the yuck factor.  I hate doing rectals and prostate exams too but during medical school I ended up with an attending on one rotation who made me do a prostate exam on every freakin patient that came through his clinic.  By the end of that rotation I still hated doing rectals/prostate exams but at least I knew I how to do it.   In medical school I never got the chance to practice the actual pelvic physical exam all that much.  I did my ob/gyn rotation before graduate school (like 6 or 7 years ago) and even then most of the women seen in the clinics weren’t comfortable with a male medical student.  I guess I really can’t blame them.  But as a result, I spent most of my clinic time during that rotation checking email. 

  But here I am 6 or 7 years later except now I’m “doctor so-and-so” and I’m expected to know this stuff.  Can you say ”mudphudder is fucked”?  That’s what I was saying all through that last rotation. 

 With a pelvic exam, there’s a particular set up (i.e. you don’t want to have to run out of the room looking for stuff in the middle of the exam), there’s a whole formality to it, and then there’s the actual exam: you have to use a speculum, find the cervix, identify discharges…  1) half the time I can even find the cervix.  2) When I do find it, what the hell does a normal cervix look like anyway?  Sort of like a pink cherio?  But sometimes it’s normal for it to be a little red.  Maybe.  I’m not sure.  3) Discharge?  There are normal discharges (which at least to me don’t look that normal) and then there are a gazillion different abnormal discharges.  Do you know what an expelled fetus looks like?  I don’t and I don’t want to know.  I’ve heard it looks mucousy, like snot.  This is what someone named ”doctor” told me.  SNOT?!?!  It all looks like snot!  What the fuck?  4) And then, what the hell am I supposed to do with a discharge? Culture it maybe.  I don’t know.   5) And then you have random things that pop-up.  Like, one time when I was all, what the hell is that string?  And then I found out what that string was for. 

  This is making my head hurt.  Is my level of discomfort palpable?  Yes.  I think it is. 

  Never ever.  Ever again.  Ever ever ever.  Done.

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the waiting

I swear, the hardest part of internship is not the long hours or the work load, it’s the waiting–the anticipation of impending pain.  The worst is when you’re sitting there on the eve of a painful 12 day stretch and you can just imagine how bad it’ll be.  Of course it’s never that bad but you can just imagine that it will be. 

All I can think about in those situations is the worst case scenario for each day.  And then I imagine having to deal with that worst case scenario day after day after day.  It never turns out that badly but of course the one time that I assume it won’t turn out that badly, it will. 

Or even a far more benign thing like a good day on the wards.  You know that by the law of averages, it’s only a matter of time before you get the clinical equivalent of a sack of bricks upside the head.  The bad day is coming. 

Yeah yeah, I’m just being neurotic but I’ve heard this from more than a few other co-interns: the anticipation will kill you.

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that’s gotta hurt

Here’s one of those posts that medical and non-medical readers might find interesting out of the same morbid curiosity to see some extreme (-ly painful) medicine. 

This wasn’t a patient of mine but rather one of those times where you see another group of doctors around a computer looking at an x-ray and collectively hear them say “DAAAAAAAMMMMMMMNNNNNNNN” so out of morbid curiosity you have to go over and see what the fuss is all about.   

Everyone together now--DAAAAAMMMMMMMNNNNNNN

Everyone together now--DAAAAAMMMMMMMNNNNNNN

I present to you a patient who fell poorly on the right ankle and destroyed it.  At least that’s the story.  You question my skepticism?  Look at that film–that’s pretty bad for a fall. 

Anyway, you see all of those red arrows I added to show all of the different places where this patient’s ankle was broken?  That’s not normal.  That’s not even the typical ankle fracture.  And I caught a glimpse of the patient.  This patient was in a world of hurt.  A world of hurt. 

So this would be a comminuted tibia/fibula (tib/fib) fracture.  It’s not an “open” fracture since the bone wasn’t sticking out of the skin but it was close.  Like bone right under the skin close.  But, I’m not an orthopedic surgeon so I won’t even pretend to know much about different fracture types, etc. so I will refer you to wikipedia…  In any case, this patient’s ankle is a bag of bones at the moment and will be going to the OR in the very near future.  And, will likely have a very difficult recovery ahead. 

One thing I will say about medicine is that just when you think your day was about as bad as it could possibly get, you see something like this and you realize things can always be worse.  Like having to manage 25 really sick patients, do 3 admissions and discharge 8 patients on a shattered ankle.  Although, on a more serious note, I will say in hindsight that there were days in graduate school where if you had taken an x-ray of my dreams/hopes/desires/career prospects, it would have looked something like this.  Who knows what I’m talking about?  That’s right, everyone with a PhD should be raising their hand.

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reality check

Just two and a half months gone in internship? Feels like 2 and half years gone by. Love the work but it’s no walk in the park. Time for a reality check: it’s Final Countdown by Europe.

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condolences to pascale

Pascale Lane, a twitterverse friend of the mudphudder’s, recently lost her cat, Denver the wondercat, after 18 years.  My condolences to Pascale.  Not too long ago, I lost my cat after 17 years.  It was heartbreaking.  I couldn’t remember a time, extending back to my youth, when I was without my cat.  And then he died. 

While for cynical me the experience was just another reminder of how cruel life can be and that everything good eventually comes to an end, Pascale has chosen to take a more practical approach and attempts to extract something useful from her experience as she reminds us that while Denver the wondercat died peacefully in his sleep, many people do not have that luxury and that we should specify advanced directives and/or discuss these end of life issues (e.g. whether to have life support–CPR, intubation, etc.) with our doctors ahead of time.  This is, of course, a hot topic item in light of recent health care reform discussions and the fact that Medicare does not cover the cost for patients to meet with their physicians to have such discussions.  I say “of course” but of course I have minimal insight on the matter as I spend most of my time as an intern and only recently found out that there even was a health care reform discussion. 

But I digress.  Pascale, you are so practical.  Time to grieve but I understand.  So in a show of solidarity and in support of Pascale as well as toward a lasting legacy of Denver the wondercat if we can get even one person to plan ahead, I too will make the pitch.  However, I am not quite as warm and fuzzy as Pascale so I will do it in my own cynical, bitter way. 

Here’s why people need to have these discussions.  1) Because they can and 2) because I don’t want to be the one making these decisions. 

I always feel especially bad when intelligent animals die.  They know and understand so much, and yet my feeling is that in the end they don’t really have an understanding of what’s about to happen.  In fact I don’t know that they have any understanding of death at all (note: animal people, DO NOT send me emails about how this species or that species does understand death–I’m speaking in generalities here).  Anyway, maybe that’s all for the best.  My cat understood health and life and enjoyed both.  You could tell from his reaction to illness and how he would seek out help from us when he was previously ill.  But at the end, I don’t think he understood the untreatable nature of his demise.  That was the hardest part for me to deal with.   He wanted help–you could tell–but there was nothing to be done.  I suspect it was similar with Denver the wondercat.  My suspicion is that if my cat or Denver had understood the impending end of the road, they would have made plans and requests in terms of how to be cared for at the end to best suit their comfort needs.  Cats are very responsible and self-centered in that way.  Of course we tried our best, but one never knows.  Only the cat did. 

Now, with people it’s a different story.  From about the time we’re 4 years old we know and understand that we will die.  It sucks but there’s no escaping it.  It’s like the direct admission that comes in 2 minutes before my shift is up every night–the one that keeps me there 3 hours past when I was supposed to go home.  It’s inevitable.  I pray that it won’t, bargain with God or Admitting (one and the same sometimes) but sure enough that direct admit will show up just as I am about to go home. 

So people have no excuse.  Don’t people want to be prepared for the end?  Is it carelessness or a selfish need to avoid an unpleasant truth?  In either case it’s plain irresponsible.  Plus, people are largely responsible for their own deaths.  Yeah, you, the dude who’s eating a big mac while reading this, I’m talking to you.  And I’m talking to me because I too am eating a big mac while writing this.   But seriously, when you think of the major causes of death, many of them are preventable (for the most part).  Heart disease, cancer (some types, e.g. lung), accidents, diabetes (type II), etc.   I don’t personally have any of these problems but I definitely see myself working towards at least 3 if not all 4.  In any case, we’re all killing ourselves slowly, so we might as well be prepared for when it happens.  Death is not a dignified process–better to make it as painless and orderly as possible. 

Which brings me to my next point.   I don’t want to be the one who has to make these decisions for you.  A lot of disorder and chaos is ensues when a patient codes and family members are arguing back and forth over how far to take the resuscitation effort.  It’s no good.  A doctor is always going to err on the side of saving a patient if advanced directives are not clear but I don’t think any doctor wants to put a patient through a lot of possible pain and discomfort during resuscitation if it’s not the patient’s wishes.  I don’t know, call us selfish or whatever, but we’d rather you made up your own mind.  You know what I’m saying? 

In any case, Pascale brings up a good point.  Think about it people and tell others to think about it too. 

Pascale, feel better my friend.

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something new

  So one of the major struggles I face as an intern is learning a new system in a new hospital. This is on top of having to deal with the new patient care responsibility. My suspicion is that learning the new system is as hard if not harder than the mounds if patient care responsibility. I am actually surprised. As a medical studnt I remmber watchng interns even residents struggling to learn our system: online order entry, online patient records, even where the bathrooms are. And, I was always a little confused about why it was so hard for them. Of course, my years of experience at that hospital probably biased my view of the ease of doing everything. Now, I have been feeling the pain for the last two months.  And I’m finally realizing one of the major benefits to stating at your home institution for residency is that you know where everything is, you know how the computers (and programs) work and you know where the bathroms are (that’s so key).  This is such a huge beneft on terms of avoiding pain. However, this advantage only lasts for about a month or two and then everyone catches up to each other. So, as I kept telling myself, my pain (at least in this regard) will only last so long. On the other hand, there are so many advantages to going to a different institution. Most importatly, the opportunity to work with new people and to see new things, experiences which can only broaden one as an individual. I think this is actually quite huge. Not only with regards to my education but also because it shows other institutions later on (eg when time cone to apply for fellowship or a job) that I can be serious about moving and starting fesh somewhere else. The institution where I did medical school is the kind if place where people stay forever.  There were definitely times when I felt that I was going to be there for going on forever since I was there for graduate school as well. And, during residency interviews, I always got the question of why should they believe that I would ever leave to go to another institution.  I always found this to be a sort of weird question–why would I spend $500 on travel and lodging for a residency interview if I wasn’t serious about it?  But it just goes to show the mentality of program directors, etc–every little detail can be interpreted in one way or another.
  So now I’ve been here for 2 months. I was asked by a close friend recently, don’t you miss [insert hospital name] and my response was NO!  It was an amazing place and maybe I’ll go back there some day (if they’ll take me as well) but if I had stayed there, I’d be in such a rut. After two months here, I’m still learning new things about how to manage patients and how the hospital works every day. And all of it is in comparison/contrast to what I learned before.
  My point is that it was very hard to break out of my 8 year rut, but now that I’ve gone through the painful process of learning a new physician order entry system, electronic patient record, PACS, etc, breaking the rut feels incredibly rewarding. For those of you who have to make the same decision or something similar (medical school, graduate school, fellowship, etc), the prospect of leaving “the known” can be quite daunting but it can be terribly informative/useful in the long run. I’m the king of staying put in my rut so if I’m saying this, there’s gotta be something to it (at least in my head).

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oh to be young again

I was walking around Harvard Square today and saw all of the little college students running around, exploring with their families, etc.  And then I thought to myself, do I even remember college?  I think I do.  I mean, I remember college and I’ve thought about it before but I hadn’t thought about what it felt like to be in college for a looooonnngggg time.  Does anyone remember what it felt like to be college?  It was so long ago (ended ~10 yrs ago) for me.  When I started, the concept of taking care of myself was pretty foreign.  I’m pretty sure that was still the case when I graduated (at 155 pounds; now I’m at 200) and likely that is still the case now (I’m at 200 pounds).  The angst.  The worries–how different were my worries then and my worries now?  Crazy.  The kind of stuff I was worried/concerned about then (too trivial to even mention).  The kind of stuff I worry about now (e.g. managing career and family, getting my research published, my patients).  The crazy shit I used to do then (you don’t even want to know).  The crazy shit I do now (e.g. running a code!).  Big contrast. 

Those kids don’t even know what’s waiting for them.  Well not entirely.  Some them probably do, but most have no idea.  The scary thing is, I still don’t have any idea.  I talk to people with kids, people who are practicing doctors, people who are researchers, people who do all three, I have no idea.  I wonder if in another 10 years I’ll look back on these days and sigh and say that I had no idea.  Probably.

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vacation recap

So I just returned from my first vacation of intern year. I started off with a couple of difficult rotations but somehow managed to get through–even learned something in the process. In all honesty, I was tired but I could have went another month easy without the vacation. Don’t get me wrong, it was nice and even at a nice time of the year (especially for Maine), but I’m looking forward to the rest of the year and I know that the time off would have come in handy during that 7 month stretch over the winter and spring without any vacation time.

Beautiful.  Just beautiful.

Beautiful. Just beautiful.

But anyway, I made the best of the situation and headed up to Maine–Acadia National Park for a week of relaxation. As a side note to anyone up in the north east who hasn’t been to Maine yet–it’s nice. Real nice. I enjoyed it tremendously. I’m used to my annual trips to south carolina but I suspect that Acadia will make a nice substitute for those years when I can’t find the time for the trip down south.  

Anyway, I think the keys to a good vacation are good relaxation and good eats.  And I got plenty of both.  It’s hard not to relax with scenary like this. 

5 pounds of lobster.  Onion rings.  Budweiser.  Does it get any better?

5 pounds of lobster. Onion rings. Budweiser. Does it get any better?

And, I was reminded why Maine is known for lobster.  I think I averaged >2 pounds of lobster per day while I was there.  As a side note, did anyone else know that lobster is really cheap this year?  I’m not quite sure why but apparently it is.  In Maine, I was paying $8 to $9 per pound.  Not too shabby.  I think it’s probably a little more expensive outside of Maine or the north east, but maybe not by too much. Anyways, I digress.  Good eats and good relaxation.  Those are the key.  I made the mistake of going hiking.  Now, hiking on it’s own can be relaxing and provide much needed personal satisfaction.  But, when you’ve spent almost every waking  moment of the last two months walking/running around the wards, up and down stairs, perhaps hiking up and down moutains is not the best idea for rest.  I kid you guys not, the medial aspect of both of my big toes are completely numb.  I’m not sure why but it’s been a gradual onset and I suspect it has something to do with running around/up and down stairs so much.  In any case, I probably should have considered this on my first day of vacation before I

At this point I was wonder if it would be more painful to jump or to continue the hike.

At this point I was wonder if it would be more painful to jump or to continue the hike.

went hiking.  Up and down 2 mountains.  For 5 hours.  With one small bottle of water.   And you know what the worst part of it all is?  When you get to the point where you know it will take you 2 or 3 hrs to finish the hike regardless of whether you turn back or keep going forward.  Painful.  Just painful.  But, all grumpiness aside, the hiking in Acadia is amazing.  I even went hiking every day I was there.  But it just helps if you’re well rested and have food/water. 

In all, it was a good intern year vacation.  It took some game-time adjustments in my activity, eating and sleeping, but I’ve come away well rested and ready to hit the wards again.  Not bad at all.

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taking care

As I sit here, on vacation in Acadia national park, I am reminded of the patient recovering from a spinal injury who asked ME how I was doing. It really is a sad commentary when the patient who is recovering from bilateral lower extremity paralysis is concerned with how the resident doing. But the point is that to take good care of our patients, we need to take care of ourselves. This has been a good vacation. Lots of good food (probably >20 pounds of lobster) and lots of good rest. I’m feeling recharged and ready-to-go for Monday morning.
I’m actually surprised by how prevalent the thought is amongst higher-ups in residency that to take good care of patients, we gotta take good care of ourselves. Don’t get me wrong–it’s not that prevalent–but I’ve been reminded of this a few times. So now in my moment if clarity, having consumed mad quantities of lobster, carrot cake and ice cream, I pass this on to anyone else in the game who may have missed the memo. Take care of yourself. It’s good for you, it’ll make you feel better and all of that will transfer to over to patient care.
Now, I’m gonna continue taking care of myself and go to bed…

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my limits

My opinion is more and more that the point of internship is to push us to our breaking points. And then a little more. I’m fairly convinced that it won’t stop even at the breaking point. I’ve already seen a few people hit that wall and it hasn’t been pretty. Especially since after all the tears, all the screaming, the work is still there to do. 

I don’t know, has anyone who has done this or is in it now, ever had the thought, “I’m only ONE person”? I have that thought like 50 times a day. Today it was like a thousand times. I tweeted today that I felt like I was gonna cry. The old school doctors are all about telling us residents how weak we are, etc. but the fact of the matter is the amount of work that needs to get done hasn’t decreased since the introduction of work hours, etc. In fact, it has probably increased. The expectation is just that now we’re expected to get it all done in a limited amount of time. And that’s it. Get it done. Don’t ask, don’t make excuses, just get it done. I got des-troyed today. A huge service, discharged 7, admitted 3. Plus anything that could go wrong did. Patients changing their minds about wanting to take their medications, patients who were doing great yesterday were feeling like crap today or having intractable pain. And of course I’m the one all the nurses come to.  Pages all fucking day. My favorite is the two-fer. That’s when two pages come in at the same time and the pager makes an especially high-pitched squeal. It’s good stuff the way that a rusty nail is good stuff to step on.  

I mean some of the stuff that comes my way is ridiculous. I was dealing with a patient who wanted to do harm to himself (without getting too specific) and received 3 pages from one nurse, each increasingly angrier than the last about giving an other stable patient something for gas. And then when I went to call back, I got a ton of attitude. I gotta tell you, on some level that hurts. I really think that the worst is when you kicked while you’re down. For me personally, that’s why I always try to be nice. You just never know when you’ll run into someone who is having a miserable day and that niceness will actually do some good. Attitude, meanness and being an asshole do not Mudphudder a happy camper make when he is getting crushed. But, what can I do?  It’s not my style to really retalliate or get into it so I just do my thing and hope that my work gets done. 

So back to my original point, I really think that each day things are made a little tougher than the previous day just to see if that’s what pushes me over the edge. I know that’s really paranoid sounding and I don’t believe it either but it sure feels that way. I got some help down the stretch today from some students on our service in getting things ready and together for evening rounds. And we just barely made it. Not only in time for evening rounds but also making it through evening rounds. After rounds I thanked the students (you gotta do that–they work so hard and you just can’t forget what it was like to be a med student) and I expressed how I felt that today our little team was very much like a rickety old boat held together by duct tape and with bubble gum plugging the leaks. We were seaworthy, but just barely, and we wouldn’t have made it without every single little contribution. It was close. Sometimes I wonder how one person can be expected to do everything in one day. Sometimes it can be ridiculous. But somehow it (usually) all gets done. 

I don’t know, maybe I’m just whining too much. I’m definitely learning a lot. Not so much through active effort (too little energy and time) but because I have to do the same crazy stuff so many freakin times that it’s hard to forget. I’ve actually started dreaming about my patients and discharging them. It’s so sad–I used to dream about other things. Right now I’ll just settle for some sleep. 

Well, now I can go and get some sleep. This weekend I work over saturday night, so I can at least sleep in tomorrow. Hopefully it won’t be too bad but it probably will be. Whatever, though. If I didn’t cry today, I won’t cry tomorrow either–probably because I won’t have the time to.

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the residency gods are fair… mostly

I have come to grips with the fact that at the end of the day, the residency Gods are mostly fair. I think. At least so far. On some days I take the worst beating of my life. On those days I feel like I have done something to anger the Gods. More than likely though, they just have forgotten about me and are instead tending to the many other residents who need the help more than I do. However, then there are days when the residency Gods smile upon me. On those days, I am spared the bullshit that turns a routine 13 hr day into a 15 hour day. On those days, I get to hit the gym before heading home for my fifteen minutes of tv and dinner before bedtime. When I first started, I was getting routinely crushed so my general feeling was that I had been forgotten by the residency Gods but now, well, I’m starting to realize that in the end, it all evens out. So I guess on average, the residency Gods think of me as, “mehhh”. I guess that’s better than not at all.

My suspicion is that there will be days when I will rescind this post and say that I have been cast into residency Hell and there will likely be days when I will be in residency Heaven. I guess we’ll take those times one day at a time. In the meantime, with the benefit of the clear thought that comes from a golden weekend, I’ll just stick with “mehhh”.

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hi

Hey Everyone! This post is meant to test out a new app I downloaded so I can write posts from my cell phone. I hope this works…

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fresh air

Yum

Yum

I think what I miss most about my previous life is fresh air.  These days I get mostly stuffy hospital air, with occasional whiffs of disinfectant.  This weekend is my golden weekend and I’m taking full advantage.  I’ve spent hours outside today.  I walked Back Bay, Coolidge Corner, Brookline Village and even a little in the West End.  And what a beautiful day.  After 2 weeks of rain, we finally got a sunny day.  I sort of wished I had been a little more productive with chores, but who cares?  I got some rest and spent some time being completely mindless.  I had dinner outdoors at a tapas restaurant on Newbury Street.  It was good.  And, I got some fresh air.

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normal

Here’s a post I wrote earlier today on my phone:

I’m not normal and my life clearly is not normal. I live in the hospital except for the few hours of sleep I get every night. I get my vitamin k  vitamin D (or lack there of) from fluorescent lights.  I’m wriing this entry as I stand in line in the hospital cafeteria for a grilled cheese sandwich. I wear pajamas all day long at work.  In my profession 80 hrs is the lower limit of acceptable time spent workig in a week. Actually, I don’t think the word “acceptable” is even accurate.

But in any case I am of the opinion that sometimes it’s nice, even therapeutic, to feel normal. So I do two things everyday to feel normal: 1) I come to work in jeans and a tshirt (ie civilian clothing) everyday. There’s something really relaxing, almost cathartic after 15 hrs in the hospital to put on a pair of jeans and go home.  It only adds an extra 4 minutes to both ends of my day to change, but it’s worth it. 2) I try to take 5 or 10 minutes everyday to sit outisde either in a hospital courtyard or even out in front of the hospital. I’ll get an iced tea +/- a chocolate chip cookie and just take in some fresh air.  It’s nice and also very normal feeling. As a sidenote, I’m not sure yet how I’ll adapt this to Boston winters but I’m thinking about it now. 

I know a lot of residents who deny themselves the chance to feel normal, either out of arrogance or feeling like they don’t have the time, but I thnk that’s a bad idea. My sense of normality is one of the ways through which I relate to my patients.  Everyone wants to be “normal” sometimes and everyone wants to relate to normal.  It’s why despite sleepiness and a list of boxes that need to get checked off pages long, I love sitting down to talk baseball with a patient.  It’s also why the same patient with untreatable cancer, for a even period of 5 minutes, will baseball with me.  Everyone wants to be normal sometimes.  Finally, occasional normalcy is also a reason why I haven’t and hopefully won’t turn into a complete asshole when the going gets tough (although some may disagree with my assessment that I’m ready not an asshole).  In any case, I should say when the going get tougher.  Plus, trying to be a little normal really doesn’t take that much time.  And as I like to say: even in medicine, 10 minutes never killled anyone, unless of course it was a code.

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whazzup whazzup?

Yeah I should probably be going to bed, but fuck it, it’s been a while so I’ll blog :-)  

One of the realizations I’ve had in the last two weeks is that internship isn’t too too bad if you don’t have much of a life to begin with.  Luckily for me, I didn’t.  I mean think about it, I spend close to 15 hrs a day in the hospital on average, which leaves me about an hour in the morning and an hour in the evening. 

I guess it’s all good though.  Someone once told me that the purpose of residency was to become a doctor not to have fun.  So be it ;-)

But I’m still lookin forward to this weekend.  I’ve worked everyday since since two fridays ago and I’m tired.  Just tired.  Last weekend I got destroyed.  It was the closest I’ve come to crying in public.  There was just so much stuff to do in each of my “12 hr” wink wink shifts that I didn’t think I’d get it all done even if I had 20 hr shifts.  It was brutal but I somehow pulled it off.  God knows how. 

But now I’m tired and I could really use a couple of days off.  My first day off of residency.  Good stuff.  I want to reward myself so I thought I’d buy some electronics or something but then the first paragraph of this post hit me–i.e. not having a life outside of the hospital–and I decided to do a spa day instead.  Yeah it’s a little soft but I think I’ll get a lot more out of a good back rub and maybe  a pedicure than an xbox, which will collect dust.  In fact I think the xbox would have the opposite effect and actually depress me each night when I came home to see it but not have time to use it.

Anyway, I better go and get some sleep now.  I hope everyone is doing well. 

More this weekend when I actually have some time.

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cure for the first week of internship: a reality check

Internship has started. Getting crushed. One week down, 51 to go in internship and 259 to go in all of residency. Plus I’m on call both days this weekend.  Time for a reality check…

Take it all in: it’s Final Countdown by Europe.

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past my bedtime

Yum.

Yum.

It’s after 9pm so I better keep this brief.  First week of internship is going… well it’s going.  Not too bad I guess.  I’m learning a lot and getting into the swing of things.  More on the specifics later, but it’s amazing how different life has quickly changed.  I feel like I’m in survival mode on most nights–just grab a something to eat and hit the hay.  Today I was shocked to get out at 5:30.  Just 12 hrs on the job!!!  Leaving me more time than I knew what to do with.  At least transiently.  I hit the gym for an old fashioned mudphudder workout and then ran across the street for some take bbq for dinner. 

I am adjusting to the fast pace of most everything–racing to get everything done at work, then racing to get home so I can have a few minutes of free time to unwind before going to sleep.  Yeah it’s crazy but it’s worth it.  I’m learning a lot everyday and it’s all practical knowledge–not random minutiae that I’ll never use.  Patient’s potassium is low, how much to replete with?  How long to bridge a patient starting on coumadin with lovenox?  It’s pretty useful. 

Anyway, I’ll write more in a bit when I have a few more hours consecutively off.  I hope you are all doing well. 

MP

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13 hours later…

And the first day of internship is done. Can’t complain–13 hours is not that bad even if I was hustling around the whole day. Picking up some thai food as a treat and then I’m going home. Thank you all again for the love that you have heaped on me in the last few days. I sincerely appreciate it.

Mudphudder out.

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