Happy Halloween

Zoro, Surgeon.

Muldoon

Last Friday, I had the rare and amazing opportunity to work with one of the preeminent poets of our time, Paul Muldoon. A 2003 Pulitzer Prize winner and poetry editor of The New Yorker, Muldoon is an Irish poet who teaches at Princeton University and is known for "difficulty, allusion, casual use of extremely obscure or archaic words, understated wit, punning, and deft technique in meter and slant rhyme" (Wikipedia). He was invited to UCSF/Berkeley and gave a medical humanities grand rounds here.

In the afternoon, he also held a special poetry workshop in which a few writers of the UCSF community gathered to get input on their poetry from Muldoon. Soft-spoken and articulate, his insight was remarkable. He then gave an hour long talk, reading a substantial amount of poetry, some related to medicine, death, birth, and meaning. His delivery was awe-inspiring, and simply his facility and knowledge of words was unsurpassed (it's a strange talent to have, but one that makes a good orator). I thoroughly enjoyed the richness of his language and poetry. It was a rare and welcome treat.

Image shown under fair use, from princeton.edu.

Resource Allocation

We got a talk by Mitch Katz, Director of San Francisco's public health department, a really daunting job. He has a fascinating approach to and perspective on health care. He really sees things from a birds-eye view, and it's an intimidating task. To him, tax-payer money needs to be funneled into optimized health care outcomes, something few people would argue with. But he faces the reality of modern day medicine, meeting an annual budget, which focuses entirely on the ethical issue of distributive justice: how do we allocate resources fairly?

For most doctors, we want the best for our patients. Expensive drugs, fancy scans, resource intensive tests, an extra day in the hospital - it's all for the patient's good. But for those patients who are uninsured or underinsured, the hospital has to absorb the costs, and San Francisco General Hospital is run by the public health department. Dr. Katz finds himself the enemy as he tries to contain costs by changing the pharmacy's formulary or mandating that only attending physicians can order certain drugs or denying the purchase of a new scanner. How can there be so many barriers to patient care? We ask. But the truth is, the bottom line matters.

Indeed, we think it's always hypothetical that a patient staying an extra day in the ICU incurring thousands of dollars in cost translates to fewer vaccines for primary prevention. Dr. Katz made a huge point in emphasizing that this is not hypothetical, that it is reality. Every test we order, every drug we prescribe, everything we do that isn't reimbursed fully takes something away from another patient. He thinks that money should be going into providing housing for the homeless because that will make the biggest impact on health care. No other doctor without a public health approach sees things this way. I find it so fundamentally important.

Hurricane Katrina

Perhaps a post too late to count, but I wanted to write a bit about Hurricane Katrina. During the disaster in 2005, Memorial Hospital was flooded and lost its electricity and emergency generators at a time when the temperature and humidity were nearly unbearable. When no governmental evacuation was apparent, staff and patients began evacuation but could not get everyone out. Some of the sickest patients who were unlikely to survive were left behind.

The ethical controversy occurred when a doctor was charged with second degree murder (though in 2007, a Louisiana grand jury refused to indict her). At the time of the hurricane, she went to the hospital to take care of the patients, many of whom were already abandoned by their health care teams. Some of those patients were suffering because the ventilators had failed and the pharmacy was depleted of necessary drugs; she administered pain-killers to some of those patients. She was accused of mercy killings of critically ill patients with lethal doses of narcotics with the intent of ending their life.

It's an important question to ask: what role, if any, should a physician play at the end of someone's life? If someone is terminally ill, has intractable suffering, is of sound mind and judgment, and requests an overdose of pain medication, what does one do? There are some who say physicians should have no involvement in ending a patient's life; it gives too much power to doctors who are fallible and who do not know everything. Others think that refusing to help a patient die who is in intractable pain is unethical of the doctor; as the ones who deal with dying on a regular basis, how can we abandon patients at this critical time? This is clearly a controversial issue and one I'm fascinated by but cannot resolve.

What if a patient says she is having trouble sleeping and asks for a prescription of barbiturates to help her sleep when you know her intention would be to commit suicide? Or what about the case of a person who needs escalating amounts of pain-killers to control his suffering until the point that he slips into a coma and passes away? How do we navigate responsibility and morality, life and death, when much of medicine is uncertain? In Oregon, physician aided death is allowed within strictly regulated boundaries. Is that immoral? Or should all the states follow suit?

Poem: Mythology, and Other Lies

Mythology, and Other Lies

How naïve was I to think that Palinurus
could resist Somnus’ call
as he pulled his third all-nighter
at the helm of a wayward ship?
Now, only the genus of the spiny lobster
pays honor to this constellation-seeker,
a pastime relegated to a past time
perhaps thirty thousand years ago
when Prometheus discovered
what we have only known this past century:
the liver, with the succor of ambrosia and nectar
defies absolution
and we might wonder
if Prometheus had not faced such procrustean punishment
what he would have done next,
whether he would have continued such philanthropy
and earned himself a following of clerisy.
Perhaps without his insight, we would never have devised
the procedure we now know as the transplant,
a term that conjures the idea of sexually ineffable bryophytes
and ferns and fern-allies.

I was once told that poesy deigns all else
but sex and the dead,
the kind of prompts that make us think of James Joyce
or Elvis or Tupac,
modern day lessons on resurrection.
Much like mules, we have history,
a history that winds and waddles canyon to crevice
finding itself perched on Parnassus, sacred to Apollo
and home to the homeless
clustered and scattered among the streets
of earthquake and fire, furious and fertile
hailing the tempest-tossed, the wind-swept.

Intersession

We just finished intersession, a week of socializing sprinkled with classes and adviser meetings. While at first I thought it was silly to have these week long transitions, I find them incredibly welcome reorientation and destressing sessions. The theme this week was ethics, and we had several lectures and small groups on how to approach ethical issues, think through them systematically, and argue for or against a course of action. The truth is, I never really liked applied ethics and a physician doesn't approach ethical theory as a philosopher would. But, what we did learn was practical and certainly the discussion of ethical problems overcomes a large activation energy in recognizing its importance. As an ethical purist though, I still find Kant's (praise be his name) theories most compelling.

Another big aspect of this week was professional development. Not only did we have our old foundation of patient care groups (which I thoroughly enjoy), we also had some scary sessions on how to plan our fourth year, the timeline for residency application, and when to take Step 2. I was able to meet with a couple faculty members for advising. Lastly, they try to emphasize professionalism in these intersessions, topics that are better taught by modeling rather than pedantics.

There was also a hodgepodge of other random topics such as master clinician rounds (demonstrating differential diagnosis and clinical reasoning of a difficult case), stem cells, and disabilities. As a whole, I thought the week went fairly well; I enjoyed seeing all my classmates again and I had a lot of fun hanging out with friends.

Specialties

After each rotation, I consider whether that could be a career. I've never thought myself a surgeon but I tried to go into the rotation with an open mind. Nevertheless, I did not find my passion here. For whatever reason, I do not particularly find the abdomen fascinating, and too much of a general surgeon's time is spent there. The rest, soft tissues, vasculature, the breast, and the neck, just don't do it for me. Anatomy was neither a strong point nor a strong interest for me, and I did not find myself drawn to the hospital care of surgical patients, even those with burns, trauma, or intensive care issues. Most importantly, I just don't feel a fit with the surgeon crowd (though of course, much diversity exists and stereotypes don't permeate the group) and I can't see myself with a surgeon lifestyle.

Of the subspecialties, I only really liked hand surgery, and I don't like it enough to give up the rest of the body. Though I like the intensity and immediacy of trauma, I do not have the personality for it and I cannot see myself dealing with that kind of injury process (especially when so much of it involves domestic violence). While I did not get much exposure, I cannot see myself doing colorectal, neuro, orthopedics, plastics, vascular, or pediatric surgery. I'm not sure about thoracic (having to go through general surgery deters me), urology, or ENT.

I also experienced emergency medicine. For a long time, I was very interested in the field, which is growing in popularity. However, I decided it was not for me. I loved the emphasis on efficient history and physical diagnosis, the procedures, and the focus on acute and life-threatening injuries. I also like the hospital-based aspect of it and the shift work hours. But after experiencing some time in that environment, I didn't feel a fit. There is a lack of appreciation, too much triage without follow-up, and the unfortunate reality that most patients in an ER do not belong there or should have had their medical needs addressed earlier by a primary care doctor.

Surgery 110

In sum, the surgery experience involved a lot of practical learning and growth. The positive aspects of the rotation encompassed the operating room and procedures. Compared to stories I've heard from others, I got to do as much or more hands-on things in Fresno than students at other locations. I feel pretty good about my suturing and I really enjoy it; even though stitching can be tedious and repetitive, I like using my hands. I got to place two chest tubes, an arterial line, attempt some femoral artery sticks, and put in a Foley catheter, which is quite good for a third-year medical student. I was given a lot of responsibility and felt that I really was the caretaker and advocate for my patients. I got to rotate through multiple services, see common surgeries (I've had my fill of hernias and gallbladders) as well as complex cases (thoracotomies, cancer surgeries), assess clinic and ER patients for surgical intervention, attend trauma activations, care for patients with traumatic injuries, see plastic surgery, and learn about burn management. I really appreciated the diversity of experiences they offered.

However, I found that the formal didactics were mediocre. I did not think I learned a large body of knowledge, though certainly I nibbled at the entity that is general surgery. I found some personalities to be abrasive and arrogant, and I experienced some less-than-optimal situations. Tensions and stress were high with the patient load we had, and I often felt that teaching was secondary to more urgent needs. I didn't find myself connecting with any particular surgery attendings or residents. Students were too busy to study outside the clerkship; though call was a unique experience, it was incredibly draining. Through much of the rotation, I did not feel appreciated, and at times, I felt like I was doing more scut (busy work) than necessary. I recognize that Fresno had a lot of constraints and acknowledge that investing in students is a tiring and difficult business, but I wish student learning was more valued.

The Purview of Surgical Practice

Surgery has become a commonplace concept, a household term, even a cosmetic high school graduation gift, but after spending two months delving into surgical practice, I still find it a fundamentally stirring concept. A surgeon takes a blade and cuts into another person's body with the assurance that doing so will leave that person better off than before he or she came in. That takes a lot of confidence (and people with confidence self-select into the field).

It amazes me. I never think of this in the moment, when I am handed a scalpel and told to make a careful premeditated incision (a euphemism for cutting on a dotted line). But afterward, I realize I had to have enough confidence in my medical judgment, knowledge, and skill to justify intentionally cutting someone. Of course as a student, my supervisors really make the decisions, but it is my responsibility to object or refuse to do a procedure if I am not convinced that the patient needs it or that I can do it safely.

This can be extended to all of medicine. Over the last six months, I've seen many patients: diabetics started on oral hypoglycemics, hypertensives that needed medication management, cuts that needed stitches, patients who needed drugs for pain. In all cases, doctors actively do something to the patient with a degree of confidence that they are doing what's best for that person's well being. Even simpler things have this quality: deciding to X-ray someone or doing a pelvic exam or taking a history. When I feel for lumps in a middle aged woman's breast or ask a man to undress to assess for hernias or ask a teenager when she last had sex, those patients trust that I am invading their privacy because I can help their health, and I, too, have to have that certainty that I can justify what I'm doing.

Surgery is the extreme. We take a naked person, we put them to sleep, we cut them open with a knife, poke around their belly, and then sew them up again, sometimes for an optional, elective procedure. Doctors have the unique position of being able to do this with the schooling that prepares us, the legal right that backs us, the experience that hopefully tells us when invading someone's body or someone's privacy can be justified. There is something quite thrilling as well as something quite scary about having that privilege.

Image is in the public domain, from Wikipedia.

Poem: Other Poems

Other Poems

In other poems, death is a persona
riding a chariot, carrying a scythe
sometimes with a bit of halitosis
or sporting a cigarette and smoke rings.
I’ve read of death teaching morals
helping old ladies cross the street
on their way to the funeral home.
In other poems, death can be funny
or grave and punny
or grandiose or peaceful
anthropomorphized and personified.
Death sometimes acts the role of a metaphor
for something lost or something gained
a bit of trickery or a hint of judgment
an insurmountable foe
at the end of the tunnel.
In other poems, death is an allusion
or an illusion, a doppelganger
that takes on any number of costumes
than that it wears at home.

Week 8

My final week on surgery was an abbreviated one. We only had clinical duties on Monday and Tuesday (along with rounding over the weekend). Other than taking care of the same burn patients, I was in a couple hand surgeries. On my last day of the rotation, they let me use a scalpel! (Actually, I had used one to put in a chest tube, now that I think of it). A young man had a pyogenic granuloma on the finger, a ping-pong sized erythematous friable (red, easily bleeding) mass forming at a site of prior trauma (he had hit his finger with a hammer). He was put under conscious sedation and I carefully cut it off. The second case was a carpal tunnel release, a quick but good procedure to see. In clinic, I saw a few standard plastic surgery cases: a thumb crushed in a car door, a breast reduction.

Tuesday evening, I drove back from Fresno to San Francisco. It's really good to be back; October is a beautiful month in the city. We had two days to study for our shelf exam on Friday. Our evaluations in this clerkship have a few objective components; we had to do an observed abdominal exam with a faculty member and present a couple annotated researched H&P's to our preceptor. But the looming menace was the shelf, which has a reputation of being quite tough. Along with a tight time constraint, the surgery exam tests aspects of orthopedics, neurosurgery, urology, and pediatric surgery, which we have to review outside of our rotation. A lot of it (surprisingly) is medical management: how to work up abnormal electrolytes or decreased urine output or post-operative fever. In any case, it was an intense exam but it went fine and marked the end of my third rotation and, more frighteningly, the half-way point of my third year.

Week 7 and a Short Break from Blogging

Aside from the burns and plastic surgery cases I did, I also had some interesting operations when I was on call. We had an intra-operative consult from ob/gyn. They were doing a hysterectomy and salpingo-oophorectomy in a woman who had many previous abdominal surgeries. As a result, she had a lot of adhesions involving her small bowel. Ob/gyn wanted us (trauma surgery) to come and take down the adhesions because of the danger of damaging the bowel. Afterwards, I got to see them do a partial hysterectomy and take out surprisingly large fibroids. It was interesting seeing the role of multiple surgeons working on one patient. We also had an acute appy which we took out laparoscopically and a patient who had a near amputation of a distal middle finger. Unfortunately, the finger was not salvageable and we had to complete the amputation and sew up the end. The other thing that happened this week was that the chief of surgery and his wife invited the students over for dinner. That was quite nice, and I learned a lot about the history of Fresno and the hospital.

I have decided to take a short one week break from blogging. The next blog will be next weekend. I'm going to use the time to study for our surgery shelf exam.

Plastic Surgery

For plastic surgery, we work mostly with a hand surgeon who I really like. Hand surgery is really different from the other surgeries I've seen. It's especially meticulous and precise, almost perfectionistic. Every motion is exactly as it's intended, every cut premeditated, every suture carefully tied. If it's not satisfactory, the surgeon redoes it. It seems that the margin of error for a tendon repair, compared to an intra-abdominal exploration, is a lot smaller. There are other differences, too. The surgeon sits, the tools are more delicate, the arm is put in a tourniquet to produce a bloodless field, and splints are used to maintain the position of various joints.

I've scrubbed into a lot of surgeries, including cyst excisions, scar revisions, tendon repair, exploration of stab wounds, palmar fasciotomies, ulnar nerve release, and scalp cyst removal. I really like the dissection of tendons, vessels, and nerves; for some reason, this is more exciting than laparoscopic dissection of the biliary tree or poking around the omentum. To be honest, if you had asked me that in my first year, I would have said the opposite; dissecting out nerves, vessels, and ligaments is horribly tedious. But now seeing the real thing, I'm really enjoying it.

Burns

This week, I switched over to the burns and plastic surgery service. They are very different entities. The burns service is a small one; as you might expect, severe burns requiring hospital stays are uncommon. The burns unit takes care of people with burns covering much of their body surface (from just 20% to 70%), deep third degree burns, burns involving the face, hands, genitals, and chemical or electrical burns. These patients are seriously ill. The patient I'm following was in a grassy hill when he fell asleep with a lit cigarette; another patient developed toxic epidermal necrolysis, a rare drug reaction with a 30-40% mortality; yet another patient is a psychotic patient who dumped herself in gasoline and lit herself on fire. It's actually really hard emotionally working in the burns unit; many patients don't even look human anymore. They cannot communicate, some have limbs amputated, and they are kept alive by invasive machines and monitoring. The surgical operation we do for these patients is skin grafting; we either harvest split-thickness skin grafts from the patients themselves or attach onto denuded tissue skin from someone else; sometimes, with large surface areas (imagine having to cover a whole back with skin), these patients look like a patchwork quilt. It's not hard surgery and students get to do a lot of suturing and stapling. But definitely not something I'd be interested in doing in the future.

Service

"Life is short and the art long, the occasion instant, experiment perilous, decision difficult." - Melvin Konner

Week 6

The second week on trauma really drained me. The days start at 6 but consistently end at 8pm, and even though 14 hours isn't absurd for surgery, ending that late ends up being really draining. I took care of a lot of ward patients (our census went up to the high 40s) but only scrubbed into two surgeries: an emergency laparoscopic appendectomy (I got to fire the stapler which cuts the appendix from the rest of the bowel) and a laparoscopic cholecystectomy. It was fun even though they are not particularly stunning procedures. The rest of the week was fairly unremarkable. The weather has been cooling down here and on Sunday, a few of us had a barbeque outside (students on other clerkships actually have free time).

Poem: Emergency

Emergency

After work, the board is wiped,
a new tally made to see who nets
the highest blood alcohol
or longest object extracted from a rectum
(I got seven inches, anyone beat a seven?)

The regulars stumble in
ordering a round, putting it on the tab
another shot of Ativan
before collapsing in bed in the hallway

Here, the sound always comes first
siren or scream, moaning or sobbing,
calling us from our stupor, winding our way
in anticipation to the trauma bay

where we hit the smell like a fist,
the burnt flesh, gunpowder and soot
the stale urine, the halitosis
the disinfectant with the sting of feces

Then the sight, the drunk men
victim of assault, now returning the favor
or the teenager status post mosh pit
or the pregnant woman rolled from a moving car

I lay hands, feel that Rice Krispie crepitus
along the neck of this upstanding
seventeen year old, shot by the owner
of a convenience store he tried to rob

The taste lingers all the way to the bathroom
where I spit up disgust and pleasure,
that adrenaline that drives me, like these people,
to come back again, again, again.

The 15 Minute Visit

How can we manage a new patient in a practical manner given a very limited interaction time? A full medical student history and physical can take up to an hour, but certainly we cannot afford that luxury in the real world. Dr. Kopes-Kerr, one of the program directors for Santa Rosa Family Medicine, tries to maximize the efficiency of a 15 minute first visit. Here's what he suggests:

-Start with the medication list.
-From the medication list, build a problem list.
-Get basic demographics, household information, occupation (especially for those of lower socioeconomic status).
-Defer family history, which is often complex, time-consuming, and low yield. Do this only if you have a clinical indication (cardiac risk profile, breast cancer, alcoholism, mental health disorder).
-Immunizations, which I personally never think of, but it's an important aspect of family medicine. Document last tetanus, flu, and pneumococcus vaccines. Copy immunization cards for children and give any that are clearly behind.
-Cancer screening: last Pap smear and if there has ever been an abnormal result. Defer all other cancer screening (mammogram, PSA, colonoscopy) for later visits.
-Lifestyle review: exercise, diet, tobacco, alcohol, drugs, stress. This gives information and also centralizes the importance of lifestyle in family practice. Do a coronary artery disease risk profile.
-If there's no chief complaint, then a physical exam isn't necessary. It may reassure the patient and build rapport, but beyond that, it's low yield in a first intake H&P.
-Instead, focus on the message the patient leaves with: what is the principal action or behavior they need to do now and why; how should they take their medications; when do you want to see them next and why.

Many people lament the lack of time in a standard clinic visit. I don't know what the answer is, but here's a possibility.

Indoctrinated (I apologize for the pun)

My hand automatically goes to my hip when I hear a pager go off.

One of my classmates was late to a lecture so the attending asked us if we had his phone number. He then called the student's cell phone directly and when the student didn't answer, he had the operator do an overhead page, "Can medical student _____ please report to lecture?" Overhead pages are announced to the entire hospital. Ouch.

-How come this patient with a hernia didn't get his labs?
-Oh, because of incarceration.
-What? Which was incarcerated, the patient or the hernia?

Observations

Skill sets are pruned as you go along. Already, I feel rusty with the mental status exam and the neurologic exam when just a few months ago, these were second nature. I purposely try to do a good psych or neuro evaluation on the appropriate patients simply to keep my skills intact.

Hospitals generate a ridiculous amount of waste. Even though we have an electronic medical record system, we plough through reams of paper a day, as well as procedure kits and other supplies. I find it worrisome.

Even medical students receive a surprising amount of respect. I'm not used to it, and I certainly don't feel like I deserve it. It's also scary that when nurses, therapists, or patients ask me for an opinion or an order, it matters. Responsibility is intimidating, and we get lots of responsibility at this hospital.

I like the fact that in the hospital, we don't have to worry about money. I'm aware of the patients without insurance, but I like being able to order what needs to be done for their health regardless of their financial status.

Rules of Surgery:
1. Eat when you can.
2. Sleep when you can.
3. Don't mess with the pancreas.