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Text of the page (random words):
suture lines falling apart but i can t stop going over the case again and again trying to decide definitely whether if i had tied those knots faster or run that suture line more adeptly or not crossed that one tissue plane that we weren t supposed to cross would he be doing appreciably better now or was he just a sick man having a high risk operation and the current problems are no more than were bound to result anyway really actually i think i probably only added 15 minutes to a 4 hour case but i operated on him i cut on him and now he s sick this is scenario is replayed for every one of my patients who encounters what last year not operating i would have regarded as a common and inevitable post op complication a bump in the road but now i touched the patient i more than touched them i was cutting things up and now things are not perfect my fault my fault my fault january 8 2010 baby steps posted by dr alice under in the or 1 comment the last few months have seen me being allowed to operate far more than previously my performance in the or seems to consist of occasional stretches of competency mixed in with a good many more episodes of apparently completely failing to grasp what i m being told to do so i rather enjoyed the other day when after about six hours of operating with one particular attending we came to a crucial and difficult step deep in the abdomen close to the aorta she was just starting to try to explain the maneuver when i had a sudden flash of insight and building on a couple of moves she d been trying to teach me all day completed the step much faster than either of us had anticipated she exclaimed where did you learn to do that you taught me earlier today that was fun wish i could do it more often usually it s a much slower process with the attending repeating unspoken as i ve already told you five times in this case don t move your hand like that do it like this january 7 2010 second chance posted by dr alice under death faith memorable patients 12 comments i admitted a patient from the er one night over the holidays the er called with a ct scan showing diffuse pneumatosis and the most obvious portal venous air i ve seen so far the patient himself looked far better than the scan and was amazingly comfortable considering that he had a heart rate of 140 and was already in acute renal failure he was so comfortable that it was very difficult to persuade either my attending or the patient that he needed emergency surgery pain out of proportion to exam alice you can t tell me he has ischemic bowel and no pain i insisted so we didn t really lose any time but it was a little disconcerting as for the patient that was the worst conversation i have ever had to have telling a family that someone died is easier telling a man who s chatting happily that he s almost certainly going to be dead within 24 hours is nearly impossible either to find the words or to convince the patient i had to not only convince him that matters were this serious but also discuss the option of surgery his only chance of survival but a very slim one with a significant chance of a long icu stay and major morbidities if he did survive some might say that with that ct scan we shouldn t operate 1 you can see pneumatosis and portal venous air from a bad bowel obstruction which can be salvageable 2 he was relatively young and with few comorbidities we never did figure out what caused his ischemia in between talking to him i was calling the chief and the attending and the or and the icu getting iv fluids and antibiotics running and moving him to preop holding not much time no sooner had i settled him in preop with a nurse to watch and the attending about to walk in than the trauma pager started going off with multiple gunshot wounds so i had to leave him three hours and several traumas later i found him and the chief resident in the icu the operation had been completely unsuccessful there was absolutely nothing to be done his body was shutting down and there was barely time to have the family at the bedside before he died i felt awful afterwards not just because it was the holidays and we had lost a previously healthy man suddenly but because i had spent half an hour talking to him about his death and had never talked about what would happen to him after death i had watched somebody dying and had never even mentioned god or heaven or hell which meant that i did him exactly no good at all he died as i knew he would and had to face eternity and i hadn t even mentioned it yesterday one of the pacu nurses came up to me at night pacu and preop are staffed by the same nurses remember that man with the ischemic bowel who died i went to the funeral home i had to tell his family something he told me that night he said i m not worried about this because i m putting it in god s hands he took care of me when i had surgery 30 years ago and he s taking care of me now if he wants me to live i will and if not it s all right if i don t make it through surgery tell my family i ll see them in heaven i started crying in the middle of pacu he s safe after all i didn t do anything i should have but he knew better than me next time i won t make the same mistake as for the nurse i have a whole new respect for her going out of her way to comfort not only the family but also the other caregivers january 6 2010 theory of relativity posted by dr alice under residency 2 comments my perspective on time in the hospital has certainly changed in the last two and a half years i remember even as recently as the end of my intern year watching the clock intently as the end of a shift got closer and being very antsy if something came up at the last minute to prevent me from leaving i also used to spend a good deal of time pondering my days off for the month and exactly when they fell and how far apart they were i don t pay as much attention to those specific times any more i come in as early as i need to so that i can round on patients to my satisfaction to me that means reviewing all the drips on icu patients reviewing and correcting all labs and reviewing the most important consultants notes for me infectious diseases before signing in with the team i stay as late as necessary to tuck my patients in for the night and make sure that i ve checked the intern s orders from the day if a case is running late i expect to stay late with the chief and don t pay too much attention to the time the work is becoming more important and the time less important which is actually less stressful it s almost more peaceful not thinking so much about time of day of course the corollary is that i m so busy i scarcely look at the time except when i need to date a note or in terms of figuring out how cases are running in the or usually not that important our or is so chronically slow and late there s always time to do another chore before the next case starts as for days off after pulling a couple stretches of four weeks straight between one month and another working two or three weeks straight through isn t such a big deal anymore four weeks though i was definitely getting pretty crazy by the end of those that was more definitely dangerous for patients than working 30hrs straight you get acclimated to anything i guess january 1 2010 not just a test question posted by dr alice under surgery 7 comments steering back to safer less political waters i ve been having a peculiar experience lately of course i ve grown inured to the embarrassment of concluding that a patient needs surgery and making my case and then being informed by the attending that i m insane there s no such indication and the patient is best left far outside the or but recently i ve encountered the slightly more disconcerting phenomenon of being told by the chief resident that the patient doesn t need surgery adjusting my presentation when talking to the attending and then being told by the attending that we should book the case for first thing in the morning depending on how much i caved to the chief i then get reamed out by the attending again or i get credit for having made the call last night was a succession of such cases a large bowel obstruction a variety that i haven t seen a lot of which people weren t convinced was really obstructed but the attending agreed with me ischemic bowel which the intern and the er doctor were trying to downplay as questionable but i knew the ct was incredibly bad and the patient s vitals and appearance were subtly hinting at the outcome which was that he died six hours later despite our best efforts i can at least be glad that i didn t waste time and that i stuck to my interpretation enough to drag both the chief and the attending in much against their wills a less obvious case of ischemia in a vascular patient requiring intervention in the middle of the night now that i ve gotten to the seniority and perhaps the reputation that the attendings will usually despite questioning me at length book the case immediately just on my say so because surgeons can t function without interrogating each other and especially their junior members regardless of how correct the plan is i m starting to encounter the weight of responsibility i have the or set up the patient consented often after being talked into it quite urgently so that i would feel incredibly guilty if i had persuaded them so firmly and was mistaken and carried down to preop everything ready to go for a major operation and all on my authority i make time no matter how much the icu is calling me to wait till the attending comes so i can see what he thinks of the patient and the ct scan i only ever once got the patient and the attending together in holding and had the attending seriously consider cancelling but i get very nervous at the idea that i virtually by myself am setting people up for big surgeries what if i get it wrong december 23 2009 the early results of obamacare posted by dr alice under politics 18 comments i ve been trying to avoid talking about health care reform or deform if you want to be accurate on here because it makes me so angry that i m virtually speechless i ve also stopped talking about politics with my liberal friends at work i used to enjoy a friendly debate but there s nothing fun about the looming disaster i can t not talk about this any more i just opened a mass email to all the physicians at my hospital informing us that in addition to compazine a very basic anti nausea medicine cheaper and more effective than zofran and less sedating than phenergan my go to drug for post op nausea and some iv narcotics and antibiotics there is now a national shortage of propofol the fast acting sedative used to induce anesthesia for a general case used as almost the sole agent for a conscious sedation outpatient procedure and relied on heavily to sedate icu patients because its very short duration of action means you can turn it off quickly to check for neuro status and trials of vent weaning and get it back on quickly if needed and we are going to be using the european variant whose key features are that people who are allergic to peanuts can t have it and it doesn t have the same anti microbial agents built in meaning it s more liable to acting as a culture tube for bacteria i can t see any explanation for this sudden simultaneous shortage of all kinds of basic drugs which i have never seen before in my career one at a time maybe and usually more rarely used drugs than that pharmaceutical manufacturers are scared stiff of the antics in congress and are trying to cut their losses by not manufacturing surpluses when they can t tell if they ll get paid properly in the near future in other words it s starting to feel like a third world country or maybe just europe and they haven t even settled on which gigantic mysterious debt riddled unworkable socialist plan they re actually going to force down our throats anyone else seeing this phenomenon too any less depressing explanations 60 disapproval rating across all polls and it s still full steam ahead who still thinks obama gives a rat s what the people really want although i have to say since a majority of the american people were idiots enough to vote for this traitor after having heard him advertise his socialist agenda loud and clear for a year s worth of campaigning it s their own fault that he s now giving them exactly what he promised and i say traitor because i mean it in the sense of someone who s committed to the destruction of constitutional government and the traditional american way of life and perhaps even national security think ksm trial in new york if any non medical people are reading this and if you ve been wondering what the medical profession thinks of obamacare i have two remarks for you the ama does not represent us and we haven t been screaming simply because we re too busy taking care of patients and too despairing of being able to stop this railroad crash to try to express our fear and disapproval and a minority of us are socialists don t ask me why guys this is how freedom is lost we re celebrating christmas we re not watching and obama and his socialist cronies in congress are about to transfer 15 of the national economy to government control after having already taken banking and finance this is going down fast i m glad i got to at least see america as a free nation although i guess i won t get to spend much of my grown up life in that country if i wanted socialism and multiculturalism gone crazy i would move to europe merry christmas december 21 2009 teachers posted by dr alice under er residency 5 comments it s starting to dawn upon me that all the chiefs and attendings i ve found very annoying or stressful have actually been teaching me a great deal most of them because it was their personal demand for excellence and thoroughness which was irritating me a very few because their laziness was forcing me to take more responsibility for being the thorough member of the team too bad that it usually takes me six months after a rotation to realize what any particular chief or attending taught me but i recognize now that my regard for getting some degree of social history my attention to looking at all the available imaging my goal of knowing absolutely all the details of the medical history before calling the chief or attending my thinking about electrolytes in the icu my thinking about dvt prevention they all came from chiefs and attendings whom i found nearly intolerable at the time because i wasn t yet prepared to think that hard or that thoroughly about only a surgical patient now if i can just think of that when i m getting annoyed at someone what is it that they re teaching me i remark on the above in order to avoid relating in detail how extremely annoyed i am at an er resident and attending who called us ten minutes before signout with a claim of appendicitis on a college aged female without obtaining a white count a pelvic exam or a ct scan i ll grant t...