So in a week I start 4th year, and I’m debating whether or not to do Radiology first, or switch it out for ENT (ear/nose/throat surgery). Youtube is a fantastic resource for budding young surgeons, as you can watch whole surgeries from the comfort of the home. Bonus: you don’t have to stand in the back of the OR looking bored!

Let me talk you through my thought process. As a quick warning, none of the links in this post are safe for children. Or adults. Or really anybody, including doctors. I’m not sure I can do ENT any more.

Zac (thinking): I wonder if I should look in to some sort of surgical field again? Honestly, I like procedures a lot. What about Urology? Nah, I don’t really want to stick my fingers up dudes’ butts all day long.
Another Med Student: Hey, man, look in to ENT! They do some really cool procedures.
Zac: Cool… lets just go ahead and YouTube some ENT stuff… lets see, this’ll do. Endoscopic Dacrocystorhinostomy.

Hey, nice nose, man. They do this while the patient is awake? That’s pretty cool, you can do it in-office. Neat-o, this is a pretty nifty, delicate procedure. Wait… wait, he’s using a “chisel”? And the guy is awake? He’s going to chisel through his nose while he’s AWAKE? Oh, god, you can hear the bone breaking. Huh, that’s kinda neat, though, he just removed all that bone and now there’s a “sac” protruding. Wait, wait, wait… he’s cutting open the sac. Oh, no – please no – now there’s stuff draining EVERYWHERE… ugh, it looks like it’s all going down the patient’s throat. I think I’m going to vomit.

Zac (nauseated): OK, ok, I can do this. That was just one surgery. How about this one… Nasolabial Cyst Excision.

Hm, that’s funny, that guy has really terrible teeth. Surgeon is getting ready to cut… nice incision, doc, strong wor- WHAT THE FUCK, WHAT THE FUCK IS THAT OH MY GOD ITS ALL DRAINING TOWARDS HIS THROAT!!!! THE IMAGE HAS SEARED ITSELF INTO MY BRAIN AND I WILL NEVER GET IT OUT… OH SWEET JESUS THAT MAN JUST SWALLOWED PUS EVERYWHERE OH GOD THE SURGEON IS MILKING THAT STUFF OUT LIKE ITS A COWS UDDER

Let me talk briefly about oral case presentations. Over the years a fairly concise format has evolved so that a large volume of information about a patient can be delivered in a very short amount of time. This format is essential to the workings of a team†, because without the standardization, you forget things. Important things. Like the lab results that came back last night, or the drug that your patient reacted to this morning. I love well-formatted case presentations.

We got to evaluate our Pediatrics Clerkship today. Normally when I evaluate other people, I give them highest marks all the way down the line, because that’s just the kind of stand-up guy I am. Y’see, I believe in people.

However, we had one attending on service that routinely interrupted everyone to tell us we didn’t know how to present, and rolled her eyes while anyone was talking. On top of that, she distinctly gave me the impression that she had no idea what she was doing. We rounded on 12 kids for 3 hours every morning, and they were the most disorganized, chaotic rounds I’ve seen all year. People interrupted, took phone calls, looked up lab results… nothing was ever accomplished.

Now, it’s very difficult to go through 7 years of medical training and still be incompetent, but somehow this woman pulled it off. I have no doubt that someday she’ll kill a kid. She probably already has. We’ll put it this way; she was wrong about almost every diagnosis for the past 3 weeks. My interns knew more than her.

So I gave her some pointers on my feedback evaluation. I sincerely hope she reads it, because I included comments like “totally inappropriate during rounds” and “failed to practice evidence-based medicine” and “was incapable of running a service“. I also included “did not feel this way about other doctors I have worked with“.

Constructive criticism’s a bitch, ain’t it?

† I’m not saying that you can’t shorten things up when a patient is well known to a team… but usually the initial presentation is fairly formal.

I was reading Enrico’s latest post and figured that I’d weigh in on a patient that I saw just today.

I, like ‘rico, am unabashedly left-wing when it comes to almost everything. My facebook “political grid” lumps me in squarely with crazies like Ralph Nader†. On the other hand, when it comes to medical issues, I tend to gravitate more towards the “do nothing” side of the “do no harm” in the Hippocratic oath. I mistrust the hospital and think most people should be at home, most of the time, and not sucking up vast quantities of expensive medical care that does nothing for them.

My patient today is a 17 year old latino male from Guatemala, who was supposedly border crossing to the mystical oasis of LA with a bunch of his friends. After being in the desert for a whopping 15 days without water†† and having finally fallen out of a tree while being chased by a wolf that was 6 feet tall, he was found down by an ambulance who brought him to our most esteemed Hospital.

He was in the ICU for 2 weeks with rhabdomyolysis, acute renal failure, massive dehydration, electrolyte imbalances, and a whole bunch of other stuff. He finally came to our service once the acute life-threatening stuff was resolved.

My immediate first thoughts on this kid were that a) he’s never going to pay, b) not only is he never going to pay, but his hospital stay is going to be far more expensive than most, and c) this is why Republicans get all up in arms about illegal immigrants.

He doesn’t legally exist here, so there is no way the hospital can track him down to pay for this – nor would he have the funds. We can’t sign him up for Medicaid, because if we did, Border Patrol will find out and deport him… again resulting in the hospital not getting paid.

And so, I find myself frustrated by this kid. On the one hand I understand the desire to get to America, land of opportunity. On the other, I wish he had brought some damn water. And on top of everything I find myself frustrated that we don’t have Universal Health Care††† and a well-implemented guest-worker program. Or something. Because as the situation stands now, we have a system of enforced charity which piggybacks on the doctors, the hospitals, and ultimately, the tax-payers.

†I still haven’t forgiven you for Al Gore, you asshole.
††Admittedly, some of his story is a little… hard to believe.
†††And I’ve already told you all that I don’t really like the idea of Universal Health Care, but hey, I’m fickle.

Our school is making us get fingerprinted. Apparently case workers and teachers do the same thing, so I suppose it’s for a good cause… but frankly, it’s obnoxious.

See, I’ve already BEEN fingerprinted at the VA, and I’m fairly certain that the government has run all sorts of rigorous background checks on me (true story, I did steal a pack of gum from the grocery store when I was 5). On top of all this, I have to go out of my way to get fingerprinted, and then to add insult to injury, I have to pay $43 for the pleasure.

Oh, and by the way, given the tone of recent emails from our higher-ups, it sounds like maybe 10% of our class has actually done this so far. Do you think they’d back down if 60% of our class just… refused?

So I went for a bike ride today, which was totally fun… until some douchebag and his Kappa Omega Kappa (that’s right, I saw your decal) frat buddies decided to buzz me as I was cruising down a steep downhill with no bike lane. Just for fun they sped up as close to me as possible and honked their horn, then drove away laughing. Who does that? Luckily I’m an expert cyclist so I wasn’t even phased.

It’s ok. Your uppance will come, eco-terrorists…

We had our student clinical exam the other day, where we have to walk in to a patient’s room, and interview, examine, counsel, and come up with a plan in 15 minutes. Then we get 10 minutes to write a note.

Honestly, I thought it was loads of fun. I really enjoyed the pacing, I loved the idea that there wasn’t an attending or resident hanging over my head checking my work (that being said, I would have been freaked out if this was real life… knowing that the only consequence was my own score was really nice), and I liked having to think on my toes.

That said, I’ve got a long, long way to go before I’m comfortable practicing medicine. I didn’t know the “right answer” for at least 2 of my patients… and although I can fool the test by writing down 3 reasonable differential diagnoses, it doesn’t cut it when it’s a real person.