It is my last day of vacation. Bummer. I have had a nice 6 days here getting some vitamin D, looking at pretty scenery, and generally chilling. We went snorkeling with sea turtles yesterday. Totally awesome. Today, I saw sea turtles at the aquarium. They looked a lot healthier in a way. I guess a life free of predators and full of regular feedings leads to a shinier shell without barnacles and other various perks.
I have noticed it takes me longer to unwind during vacations the further I get into this medical training adventure. The further you go, the more stress and responsibility builds up. While I have always preferred to take trips to cities or to do things outdoors on vacation, I am starting to see the appeal of the do-nothing vacation just for this reason.
There is an interesting Atul Gawande article on the Senate Health Care bill. Check it out.
Okay, off to the beach one last time. Tomorrow I will be spending on the airplane, so I'd better get some fresh air while I can.
Friday, December 11, 2009
Wednesday, December 9, 2009
Vacation
Ahh... vacation. The joy of doing nothing except eating, sleeping, relaxing, and taking in all of the tropical beauty around me. Hawaii rocks, and I highly recommend a trip if you have never been. Over the past few days I have hiked through a rain forest to magnificent waterfalls, done a lot of swimming, eaten tons of coconut shave ice and guava juice, and generally chilled at the beach. It sure beats work. Pictures to come upon my return to the mainland.
Thursday, November 26, 2009
Happy Thanksgiving!
Happy Thanksgiving everyone! The Lone Coyote is finally emerging from a 2 month block of brutal scheduling, where she barely had time to eat and pee, much less blog. She is very thankful that no elective surgeries are done over the Thanksgiving weekend and she is not on call, so she now has 4 days off to rest up.
On that note, let me mention one thing I am very thankful for. Pathology Assistants. If any of you out there are applying to pathology residencies, one thing you should try to get a sense of is how much grossing you will be doing in residency. You need a program where the volume is high enough that you will see interesting things, but not where it is so high that you will be grossing all of the time. Grossing can have very little educational value if you are just cutting in small ditzels and cassetting biopsies for hours. We are a very high volume program and have PA support. They do a lot of the small stuff and free us up to focus on learning how to do the bigs. This makes our grossing days sometimes heavy, but doable.
This past week I had a grossing day without PA help due to vacations and it was a nightmare. We are talking over 14 hours of cutting, much of it being of little learning value. Then you ge tto go and try to take care of all of your other work. By the end of a day like that you are just cooked and resentful. I have talked to people who routinely have days like this in their residencies. I cannot imagine doing that day-in and day-out and surviving, much less learning much of value. So be careful. Find a place where you do not just work long and hard on grossing days doing volume, but you do good cases. There is no glory in being a cutting scut monkey.
Okay, off to enjoy the holiday. I will try to be better about posting now that things should improve schedule-wise.
On that note, let me mention one thing I am very thankful for. Pathology Assistants. If any of you out there are applying to pathology residencies, one thing you should try to get a sense of is how much grossing you will be doing in residency. You need a program where the volume is high enough that you will see interesting things, but not where it is so high that you will be grossing all of the time. Grossing can have very little educational value if you are just cutting in small ditzels and cassetting biopsies for hours. We are a very high volume program and have PA support. They do a lot of the small stuff and free us up to focus on learning how to do the bigs. This makes our grossing days sometimes heavy, but doable.
This past week I had a grossing day without PA help due to vacations and it was a nightmare. We are talking over 14 hours of cutting, much of it being of little learning value. Then you ge tto go and try to take care of all of your other work. By the end of a day like that you are just cooked and resentful. I have talked to people who routinely have days like this in their residencies. I cannot imagine doing that day-in and day-out and surviving, much less learning much of value. So be careful. Find a place where you do not just work long and hard on grossing days doing volume, but you do good cases. There is no glory in being a cutting scut monkey.
Okay, off to enjoy the holiday. I will try to be better about posting now that things should improve schedule-wise.
Sunday, November 15, 2009
Time Flies
It is hard to believe it is the middle of November already! Such is life, I suppose, when working really long days with tons of cases to deal with. I am more than halfway through a 2-month block of surgicals right now at our main hospital. This is definitely the roughest section of my schedule this year and it is wearing me down. On one hand I am "in the groove" in terms of rolling with the schedule and getting my cases done. On the other hand, it is a long stretch to work at such high intensity and the burnout starts to set in after about the 5th week.
When I think about how many patients cases I have seen, it is pretty mind-blowing. Sometimes clinicians call and ask, "do you have results on Mrs. Smith's biopsy?" They seem shocked when I have no idea who Mrs. Smith is. If she has a rare presentation or an awful diagnosis I can often remember who it is once they tell me some history. But if Mrs. Smith had a standard GI biopsy that showed nothing, I have to look it up with the medical record number. It is just a different way of caring for patients. The resident on the other end may have a handful of patients that they know well. I have stacks of "patients" that I know 1-2 sentences of history for and am constantly trying to turn over cases.
I am looking forward to December when I get some elective/vacation. The temptation after all of this is to do very little on elective, but at the same time we are expected to use the time to fill in gaps in our education. It will be nice to do some work at a more relaxing pace though.
When I think about how many patients cases I have seen, it is pretty mind-blowing. Sometimes clinicians call and ask, "do you have results on Mrs. Smith's biopsy?" They seem shocked when I have no idea who Mrs. Smith is. If she has a rare presentation or an awful diagnosis I can often remember who it is once they tell me some history. But if Mrs. Smith had a standard GI biopsy that showed nothing, I have to look it up with the medical record number. It is just a different way of caring for patients. The resident on the other end may have a handful of patients that they know well. I have stacks of "patients" that I know 1-2 sentences of history for and am constantly trying to turn over cases.
I am looking forward to December when I get some elective/vacation. The temptation after all of this is to do very little on elective, but at the same time we are expected to use the time to fill in gaps in our education. It will be nice to do some work at a more relaxing pace though.
Wednesday, November 4, 2009
On Street Sweeping and Other Musings
It was a light-ish day on frozen sections so I had some time to ponder a few random things. An update on my last post about ENT surgery: we have had more eyeballs arrive, so it seems that enucleation is done at least somewhat frequently here by them. There is an Eye Pathology department that some of the eyes seem to go to. But it is unclear to me when they go and when they do not. Hence the reason why we sometimes get to cut them up. Yuck.
I was driving in the other morning and there was so much traffic approaching the hospital. It was just bizarre. Looking ahead I realized that the street sweepers were out since it was within the designated street cleaning time. And driving all around me were huge vehicles--SUVs and trucks. After a few minutes of inching slowly along the street, I suddenly realized that all of the SUVs and trucks were circling the block and waiting for the street sweeper to move on. Then they were swooping in to claim the few spots that were large enough for their huge vehicles. It seemed pretty cut-throat. I have always wondered how people can deal with owning large vehicles in the city and parking them on the street. Now I see it can be quite the sport a couple of mornings a week.
My best frozen section of the day involved being called down to the OR long before the specimen was ready. As I stood there waiting, I watched chaos unfolding around me. It seemed this surgeon was driving the nurses crazy by making constant demands. They were running in circles trying to meet all of the surgeon's requests, which held up the frozen even longer because I could not get the specimen and leave. Finally, the surgeon realized I was still standing there and demanded to know, "what are you still doing here?" "I'm waiting for the specimen."
Now he got pissed. He started yelling at at the circulating nurse, "why is she still waiting? What are you doing? Go and get the specimen and give it to her. I need this analyzed and time is being wasted." One of the scrub nurses chewed him out a bit, "maybe if you stopped asking him to get you so many things, he could get the specimen ready!" I was happy to get the specimen and get out of there as the fireworks started,
Then we get the frozen done quickly, diagnose cancer, and I run down to the OR with the results. The freaking case is done and the patient is in the recovery room already! Yeah, that frozen was really so important for the outcome of the case. How fitting.
I was driving in the other morning and there was so much traffic approaching the hospital. It was just bizarre. Looking ahead I realized that the street sweepers were out since it was within the designated street cleaning time. And driving all around me were huge vehicles--SUVs and trucks. After a few minutes of inching slowly along the street, I suddenly realized that all of the SUVs and trucks were circling the block and waiting for the street sweeper to move on. Then they were swooping in to claim the few spots that were large enough for their huge vehicles. It seemed pretty cut-throat. I have always wondered how people can deal with owning large vehicles in the city and parking them on the street. Now I see it can be quite the sport a couple of mornings a week.
My best frozen section of the day involved being called down to the OR long before the specimen was ready. As I stood there waiting, I watched chaos unfolding around me. It seemed this surgeon was driving the nurses crazy by making constant demands. They were running in circles trying to meet all of the surgeon's requests, which held up the frozen even longer because I could not get the specimen and leave. Finally, the surgeon realized I was still standing there and demanded to know, "what are you still doing here?" "I'm waiting for the specimen."
Now he got pissed. He started yelling at at the circulating nurse, "why is she still waiting? What are you doing? Go and get the specimen and give it to her. I need this analyzed and time is being wasted." One of the scrub nurses chewed him out a bit, "maybe if you stopped asking him to get you so many things, he could get the specimen ready!" I was happy to get the specimen and get out of there as the fireworks started,
Then we get the frozen done quickly, diagnose cancer, and I run down to the OR with the results. The freaking case is done and the patient is in the recovery room already! Yeah, that frozen was really so important for the outcome of the case. How fitting.
Tuesday, October 27, 2009
The Mystery of Otolaryngology
The unbelievable has happened this week. I have been home before about 9 or 10 pm in the evening! With all of this free time I hardly know what to do with myself. Perhaps that is why I began to ponder otolaryngology.
Ah, ENT, a specialty that medical students strive to match in. But after being exposed time and again to the specialty in the OR and the gross room, I really have to wonder why is this field so popular? The high income aside, of course. Maybe someone out there in the blogosphere can enlighten me on this?
Here is the way I see it. The surgeries that we get specimens on are long, brutally long, lasting the whole day or even into the night. They seem to involve digging around in very small spaces in the face with random names that I tried to block out of my brain soon after that unit in first-year anatomy. Even worse, these spaces are often filled with puss, fungus, tumor, necrotic debris, or other goodies.
They dig and dig to pull out a tiny little piece of tissue and then call us for a frozen section. Um, okay, we'll see what we can do with this limited sample. Granted it is being pulled out of someone's maxillary sinus so it's not like any more tissue can be obtained. Sigh... but it can make things difficult.
Then the next day the specimen arrive on my bench in 19 tiny parts which all have to be measured, inked, and dictated. If they need decalcification it slows everything down for another day.
Wait, this was supposed to be about ENT, not my work, so I digress. But let's talk about enucleation for a minute. I hate these specimens. Not a lot grosses me out at this point, but seeing an eye staring up at me out of a container really freaks me out. The eye had a long suture attached to one end. When I called the ENT surgeon (very nice guy) to ask about orientation, he told me, "oh that was just for us to pull on."
Whoa... pulling eyes out of the socket. Another reason, or not, to do ENT.
Ah, ENT, a specialty that medical students strive to match in. But after being exposed time and again to the specialty in the OR and the gross room, I really have to wonder why is this field so popular? The high income aside, of course. Maybe someone out there in the blogosphere can enlighten me on this?
Here is the way I see it. The surgeries that we get specimens on are long, brutally long, lasting the whole day or even into the night. They seem to involve digging around in very small spaces in the face with random names that I tried to block out of my brain soon after that unit in first-year anatomy. Even worse, these spaces are often filled with puss, fungus, tumor, necrotic debris, or other goodies.
They dig and dig to pull out a tiny little piece of tissue and then call us for a frozen section. Um, okay, we'll see what we can do with this limited sample. Granted it is being pulled out of someone's maxillary sinus so it's not like any more tissue can be obtained. Sigh... but it can make things difficult.
Then the next day the specimen arrive on my bench in 19 tiny parts which all have to be measured, inked, and dictated. If they need decalcification it slows everything down for another day.
Wait, this was supposed to be about ENT, not my work, so I digress. But let's talk about enucleation for a minute. I hate these specimens. Not a lot grosses me out at this point, but seeing an eye staring up at me out of a container really freaks me out. The eye had a long suture attached to one end. When I called the ENT surgeon (very nice guy) to ask about orientation, he told me, "oh that was just for us to pull on."
Whoa... pulling eyes out of the socket. Another reason, or not, to do ENT.
Monday, October 19, 2009
Garbage In, Garbage Out
Sometimes when I go down to get specimens from the ORs for frozen sections, I feel like there is a huge disconnect between us and the surgeons regarding how we do our job. I guess it must seem that we appear, pick up the piece of tissue, disappear for awhile, and come back later with the results. It's magic: tissue in, diagnosis out.
Let me tell you, it is not quite that easy. And to make the magic work there are a few things that can help the spell along. Unfortunately, we sometimes do not have much help in this regard. Here are just a few examples.
1. Adequate specimens. Okay, you gave me a huge container with a piece of Telfa in it that I race back up to the gross toom. Is there anything here? Maybe if I hold the Telfa up to the light... oh, wait, there is a tiny fragment of soft tissue that is maybe 0.2 cm? On a good day? Hmmm... now you are angry because because we need to "defer to permanent" to really call what it is? Let's think about this for a minute...
2. Bovie-licious. In the same vein... I return to the gross room with another container and open it. What is that smell? Is that a new BBQ dish in the cafeteria? Or the smell of the fast food from across the street? Wait... that is wafting off of the specimen. Singed flesh smell. The specimen is charred, black ball. Guess what we see under the scope? Bovie artifact! And maybe not much else.
3. Clinical history. Believe it or not, we do play a role in the patient's care. Yes, the patient's care. We're not just looking at tissue in a vacuum. It helps to have some clue of why we are even looking. That box on the specimen requisition sheet about clinical history? Just one legible sentence with the patient's presumed diagnosis or presentation and the surgery they are undergoing can be a big help. Oh, and when I ask for history in the OR, speaking clearly and not being rude is really helpful too.
4. Orientation. I am not a mind reader. And, unfortunately, I was not there when you pulled that tissue margin out of Mrs. Jones' pelvis. So there is really no way for me to know which side of the specimen is anterior. Putting in a suture to orient the specimen and telling us what it is can go a long way. Oh, and about those sutures, please just keep it simple. If I see a rainbow of different lengths of various suture material sticking out of the tissue from every possible angle, it's just a hot mess.
Let me tell you, it is not quite that easy. And to make the magic work there are a few things that can help the spell along. Unfortunately, we sometimes do not have much help in this regard. Here are just a few examples.
1. Adequate specimens. Okay, you gave me a huge container with a piece of Telfa in it that I race back up to the gross toom. Is there anything here? Maybe if I hold the Telfa up to the light... oh, wait, there is a tiny fragment of soft tissue that is maybe 0.2 cm? On a good day? Hmmm... now you are angry because because we need to "defer to permanent" to really call what it is? Let's think about this for a minute...
2. Bovie-licious. In the same vein... I return to the gross room with another container and open it. What is that smell? Is that a new BBQ dish in the cafeteria? Or the smell of the fast food from across the street? Wait... that is wafting off of the specimen. Singed flesh smell. The specimen is charred, black ball. Guess what we see under the scope? Bovie artifact! And maybe not much else.
3. Clinical history. Believe it or not, we do play a role in the patient's care. Yes, the patient's care. We're not just looking at tissue in a vacuum. It helps to have some clue of why we are even looking. That box on the specimen requisition sheet about clinical history? Just one legible sentence with the patient's presumed diagnosis or presentation and the surgery they are undergoing can be a big help. Oh, and when I ask for history in the OR, speaking clearly and not being rude is really helpful too.
4. Orientation. I am not a mind reader. And, unfortunately, I was not there when you pulled that tissue margin out of Mrs. Jones' pelvis. So there is really no way for me to know which side of the specimen is anterior. Putting in a suture to orient the specimen and telling us what it is can go a long way. Oh, and about those sutures, please just keep it simple. If I see a rainbow of different lengths of various suture material sticking out of the tissue from every possible angle, it's just a hot mess.
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