Birthday wishes

Things you don't want to say on your 27th birthday: "This is 22-year-old woman with a history of malignant rhabdomyosarcoma now admitted for her fourth course of palliative chemotherapy for treatment-induced metastatic osteosarcoma. Oh, and tomorrow is her birthday."

Operational knowledge in the operating room

The first time it happened, I barely managed to stop from yanking my hands off the field. I’d been working to quell sharp reactions, the too rapid movement of my hand to catch a falling instrument or the too quick jerk of my head to avoid blood from a pumping artery. So when the first of the pop-off needles being used to place interrupted sild sutures came flying out of the field to land perilously close to my hands, I quashed my instincts and contented myself with a sharp twitch.

My movement nevertheless sufficed to draw the attention of the all-seeing scrub nurse. She was a presence in this particular operating suite because she was the only one who could both tolerate this particular surgeon while keeping his notorious temper in check, and she gave me a look over the top of her mask, half warning and half commiserating. The first time I’d scrubbed in on one of his notoriously complex cases, she had warned me to keep my hands well clear when needles and knives were moving about. “I really am,” the surgeon cheerfully agreed.

Since the flying needle was the first of dozens — the surgeon’s technique for creating intestinal anastomoses drew snickers from residents and criticism from other attendings when he wasn’t in the room — I calmly drew my hands back from the field and folded them against my chest. But a few minutes later, after briefly holding some retractor or other in my role as third assistant, I was surprised when a flying needle driver bounced off my knuckles. My hands had returned automatically, well-trained in my first few days on the surgical service to remain well advanced on the drape where everyone could observe the medical student maintaining sterile technique.

This scene was repeated twice more before I twitched again, glanced around, and then slowly drew my hand to surreptitiously examine my right thumb where the needle had poked me. I rubbed the spot. Yes, there was blood underneath the glove. I mentally walked through scrubbing out and washing my hands thoroughly before rejoining the team in the OR. Then later I would visit the occupational health folks, fill out a report, and then wait anxiously for the results of hepatitis and HIV blood tests on my patient. I did all this while remaining standing at the operating table. I tried to remember whether this patient had any diseases, only to realize that barely knew the name and chief complaint of this woman whose intestine I was holding. Only after the procedure was finished did I take a moment to wash the spot of now dried blood from my hand. I scrolled through her medical record: hepatitis C positive but minimal follow-up and no viral load. A quick search reminded me that there’s no hepatitis C post-exposure prophylaxis and so I contented myself with telling one of my residents and convincing him to order a HCV viral load.

Do I know why a two-layer anastomosis with interrupted silk sutures is better than a single layer procedure or a stapled closure subsequently oversewn? Do I understand current rationale for and against bowel preparation before intra-intestinal surgery? Do I even understand the indications for surgery in most of the complex reoperatve cases this surgeon took to the OR during my time on his service? Do I have a better abdominal exam or ability to detect thyroid nodules? No, I don’t.

Do I know how to behave in an OR? Do I know not to challenge a surgeon about using disproved regimens or prescribing aminoglycosides for a single post-op fever? Do I know not to make a fuss about needle sticks, especially when there’s no post-exposure prophylaxis? Do I know how to appropriately raise my concern that our chosen surgical technique risks seeding a tumor and how to keep quiet when these literature-supported concerns are rejected so that the wrong procedure can be undertaken simply because that’s what the surgeon wants to do? Do I know that you can rise the pinnacle of the surgery profession and remain a miserable human being practicing antique medicine who is dangerous to his colleagues and patients? Absolutely.

The kingdom of the sick

"Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place."
— Susan Sontag, Illness as Metaphor

It is not difficult for me to imagine the terrain of the country that Sontag discovered during her battle with cancer. Flat and bleak and barren, brown grass sprouts underfoot and, rising in the distance, a grim mountain range. One doesn’t want to know what lives on those dim granite slopes, much less what’s on the other side. There is no water to drink, or perhaps only oily puddles obviously polluted. Vultures circle overhead, and vicious beasts sharp of tooth and claw and utterly lacking in mercy roam the plain.

Though perhaps not identical in each person’s nightmares, such landscapes possess an unusual ability to be shared and accepted between groups. “In the same sense in which we speak of religion or language or kinship as cultural systems, we can view medicine as a cultural system, a system of symbolic meanings anchored in particular arrangements of social institutions and patterns of interpersonal interactions.” Medicine’s economic, social, and scientific centrality in America is growing because a society that often rejects the very notion of a higher power and whose every segment advances a distinct moral geography has adopted illness as its shared negative referent. In illness, Western culture found a manifestation of “the bad” common to its many subcultures, a collective reference point for identifying evil in the world. As a result, we believe with well-nigh religious conviction that no resident of the kingdom of the well would choose to dwell in the evil place longer than necessary. What happens, then, when a denizen of the kingdom of the sick surrenders his passport to the kingdom of the well? Who chooses permanent residency amongst the wolves of illness and why? I’m not referring to the terminally ill, whose citizenship in the good world has been revoked, but to someone who by medical criteria could travel back to the sunny fields of health. Someone who becomes a permanent resident of the sick world and, in the view of the medical establishment or family or friends, does so voluntarily.

First med school final

I know that I'm realy procrastinating when I take time to read blogs and post here.

How I cook

This sounds eerily familiar.

If I wrote for The Onion...

Lutefisk replaces gefilte fish at Iowa seder

NPR on online dating

I recently decided to try JDate-ing again. I put the gruesome behind past me...oops, I mean put the past behind me. [Blogging aside: making jokes that literally noone will ever read besides me is strange. Writing inside jokes that literally noone would get when literally noone will ever read them is even stranger.]

Anyway, I remain very ambivalent about online dating. It's such a strange way of getting over being shy, since its essentially a written version of the bar scene where so many e-daters can't succeed.

An article in the Times used an intriguing metaphor for online dating. Other adjectives? Dead-on and insulting. Writer Irene Sherlock compared posting an ad to the freebies we leave out by the curb on large item collection day. The chair that is a little too comfortable to be respectable anymore; the trusty frying pan displaced by the Calphalon set; the three-ingredient cookbook that fed you for that first year out of college. Because it's a little disused or out of date or been replaced, your stuff is set out in public view in the hopes that some soul will come along and claim it. Simultaneously accurate, humorous and depressing.

The author, besides having a great name, is a college administration drone who apparently also has managed to write for the Times and read her essays on NPR. There's just something about those NPR readings. I can go through a whole essay and enjoy it. But if something makes me transmute it into that half-ironic, low, thrilling tone used for such things on NPR's All Things Considered, I find myself loving it. I think it's because the essay so perfectly put sound to the whimsicality of the article. A treat for the eyes and the ears. Imagine, for instance, hearing someone introduced as "Dr. Richard Friendman, a psychiatrist at Cornell Medical Center" read this aloud.

Music

I recently got to go on an iTunes shopping spree thanks to my parents' Hanukkah generosity. I bought a lot of country, some really good stuff that other people would like if they could get past the fact that it was in fact country. Or maybe not. Regardless, I really like it.

I also made extensive use of the "what other people bought" links. And even the "most popular" lists. Of course, this is iTunes so it's generally more hip but "popular" nevertheless usually equates to bad. Interestingly, the most popular album was the soundtrack from Garden State. It's actually a decent mix; I actually bought the whole Coldplay album

The problem is, as I watch people my age start to do remarkable things, I can't help but compare it to where I am. Sometimes these things are not actually so remarkable, i.e. Britney Spears. But Zach Braff wrote, directed and starred in a movie that had many flaws and a few serious ones but still felt true to me. Natalie Portman is beautiful, smart, and talented. Why since graduating have I suddenly become envious of celebrity?

But it's not just movie stars either. Even Sam Means seems to be on a path to literati/hipster prominence. John Teti is going to do the same in TV journalism. I can feel good about my chosen path and my prospects, but merely getting into a top school is not in itself an accomplishment. Despite what everyone says. More importantly, being a doctor is remarkably unoriginal and will rot my creativity. The people who are most successful -- using any measure of success one chooses -- are most often those who carve out their own niche. I could name people in just about every field that fit this description and whom I envy: journalism, literature, the arts, medicine, entertainment, teaching, law enforcement, politcs. Hell, at this point it almost seems like my dad fits in this category. What scares me most is that I will fail to do this.

Christmas Eve Eve

Mass. General has an official holiday tomorrow, so most of my coworkers won't be in. But I will be. Even today, most people started their Chirstmas vacation early and left shortly after lunch. Normally I enjoy days like wgere the lab is empty. I'm productive and I can listen to country music without having take a bunch of noise off everyone who walks by my bench.

But tomorrow it seems pretty sad. Me, I've got no plans for today or tomorrow or the next day. Shouldn't I be getting together with friends for eggnog or something?

The Purpose of Medical School

I'm reading a very interesting book about Paul Farmer, MD, PhD, entitled Mountains Beyond Mountains. Other things are more interesting, but a minor quotation made me pause: "Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community."

This seems fundamentally obvious. Yet I'm gradually coming to realize that the tremendous debt medical students accumulate prevents most from using their education in accordance with this principle.