well here i am, into my 5th month of surgical training. i don’t know what kind of perverse rationalization and/or profound self delusion got me into this mess, but here i am, knee and elbow deep in soap suds enemas and the glorious, if not malodorous world of general surgery internship.

somehow, when i was a kid, i never imagined that i would be waking people up at 5 in the morning, asking them if they farted, pooped, or peed. or that i would sometimes be digging my finger into a demented senior citizen’s bumhole in a sisyphean effort to scoop out loose excrement from a massively dilated rectum.

seriously man, what the hell?

debt? love of digital rectal exams? perhaps an unhealthy affinity for feculance. who the hell knows.

i have about 10 cases under my belt. picking out a lipoma is more fun than i thought. it’s like when you pick a good size booger, except better. except when you pick a booger you don’t have to write a post op note, dictate an op note, write post op orders, or see your booger back in clinic in a week.

masochistic moral superiority

i think a lot of general surgery revolves around masochistic moral superiority, in various interpretations of the phrase.

i think we tend to look down on people who we perceive to be slackers. like anesthesiologists for example. nurses. radiologists. even surgical subspecialists.

why? masochistic moral superiority. it’s like some relic from medieval times when people punished themselves to stay morally pure. like when religious people do all sorts of shit to themselves for having the weakness of mind and spirit to actually enjoy life. as if self punishment is good. i don’t know why general surgeons like punishing themselves. but it’s undeniable that we do.

i guess it’s the hope that after all the training and the beat down, we can become the type of people we wish to be. supremely knowledgeable, able to handle any acute problems, being a badass that knows exactly what to do at all times…  or is it “sometimes wrong, never in doubt”?

why do i want to become that person and at what cost? whatever happened to the common sense view that enjoying life is the best way to enjoy life? somehow along the way, i’ve been taught to think that delaying gratification was the best way to have a happy life. and now that it’s no longer about delaying gratification but not having any hope of it at all, i have to stop and wonder, what the hell? what is so devoid in my life that i need to become some sort of hero, taking on society’s bullshit burdens?

they say internship sucks and it gets better. i ask, why can’t it get like… a lot better? am i bold enough to ask whether it can actually be good, rather than just being “better than shitty”? i think some people go to work excited about their day and find fulfillment and possibly joy from their work. i really see no hope of that in medicine. i like operating and i think i have as much natural ability as anyone when it comes to manual dexterity. not that it matters. what matters now is being able to write fast because everything is done by paper and all i do is write bullshit orders, bullshit H&Ps, bullshit progress notes, and bullshit discharge summaries. i haven’t looked forward to a single day of my 10 weeks so far, and some days i go in with a sense of dread that accounts for not only the drudgery of the day ahead but also the entire year, entire residency… perhaps entire career. going to work at 5:30am everyday gets old and i don’t know that i will ever get used to it. and why should life be about getting used to pain? i am smart, accomplished, and i work hard. so why should i suffer?

i have also found out that i care little for the welfare of others. it is sad when the first thing you think about when someone dies is taking them off the patient list. one less patient to round on, right? cast the first stone if you’ve been through the hell of internship (a real one) and never once felt the same way. not that i have to defend myself because i’m fairly apathetic at this point.

oh well back to work to check pulses and spend 5 hrs writing notes that no one reads.

the best and worst of surgery

one of the worst things about working in general surgery at the VA is that the people in the ED and urgent care are unqualified to do their job. The ED at the VA is staffed by a motley crew of “doctors” who have no business running the emergency department nowadays. For those who think the days of family medicine docs, internists, and burned out surgeons running the ED are over, come to the VA. But the ED isn’t too bad, after all, they are staffed by physicians. Even worse is the Urgent Care department at the VA. These are run by nurse practioners, who for the most part seem to have no idea what to do about anything.

Examples of “consults” I’ve gotten from Urgent Care:
“help, this patient has cellulitis, I don’t know what to do. I called the internist but they said that this patient was operated on a month ago and so I should call you guys”

my response: keflex 7 days. thank you for this most interesting surgical consult. will sign off.

“help, this patient has a sebaceous cyst. Normally I would drain these myself but it’s on the chest, and I just don’t know the anatomy of this area well enough.”

my response: are you fucking kidding me? you mean this special area called the chest that is routinely lopped off for cancer, which has no major functional nerves, no major blood vessels, and has minimal cosmetic use for this 70 year old man? that one? so i cut that open and man was that nasty.

“help, this patient has an abscess on the calf. Normally I would drain these myself but it’s a bit more than I can handle”

my response: have you called ortho already? yes? damn. wait, have you gotten an xray yet? you have? shit. IS THAT WHY I’M GETTING THIS CONSULT AT 5PM?

These worst thing about these urgent care “providers” is that they always call at the end of my shift, and they always claim “I would usually do this myself but this is a special case”. This is completely bullshit. What kind of idiot needs surgery to help them treat cellulitis? I&D? What’s so special about the chest or calf again? At one point I got two consults in a row for cellulitis and I just about went crazy.

So that’s the worst thing about surgery at the VA. They think we are random steel wielding mercenaries that will do any bullshit procedure they want us to do.

Then there are the consults I get from Internal Medicine. They are always the funniest because most of them are from attendings, and most of them are completely pathetic losers. I got this one consult from this panicked internist who incidentally found a biliary stent on a KUB. Somehow it got lodged in the wrong spot and they consulted me for “a surgical intervention to take this out.” Check out this conversation:

me: what’s his bilirubin, LFT’s?
loser: total bilirubin is 0.2, LFT normal.
me: is the patient sick?
loser: no, he’s actually doing fine, totally asymptomatic.
me: is this an emergency? doesn’t sound like it.
loser: well, this can result in a lawsuit.
me: oh so this is a cover your ass emergency, not a patient is dying emergency
loser: yeah.
me: have you consulted GI for an ERCP?
loser: yeah they’re going to do it in two weeks.
me: ok so what’s the problem?
loser: well, i was hoping surgery could be involved to see if this can be done sooner.
me: ok well, to take this thing out surgically, we would have to open up his abdomen, and get all the way to the pancreas, then open up the pancreatic duct to retrieve this. i don’t think that’s an appropriate solution to an asymptomatic misplaced stent, do you? besides, i don’t we would be able to do this within two weeks.
loser: ok, yeah you’re right.
me: let me know if his status becomes worse. otherwise, THIS IS NOT A SURGICAL ISSUE.

WHAT A LOSER. THINK ABOUT THIS FOR A SECOND RETARD. WOULD YOU WANT SOMEONE TO OPEN UP YOUR BELLY AND MOVE ALL YOUR BOWELS OUT OF THE WAY, OPEN UP THE PANCREAS, AND RISK POTENTIAL INJURY TO YOUR PANCREAS, DUODENUM, BILE DUCTS, SUPERIOR MESENTERIC ARTERY AND VEIN, ALL BECAUSE THEY DIDN’T WANT TO WAIT TWO WEEKS FOR AN ERCP? AND HOW WOULD YOU FEEL IF YOU HAD THIS DONE TO YOU AND YOU FOUND OUT THE REASON THEY COULDN’T WAIT TWO WEEKS IS BECAUSE THEY HAD TO COVER THEIR OWN ASS?

it’s not like we’re fucking cowboys here. believe it or not, i went to medical school. i wear a white coat. and i often wear a shirt and tie. we’re not your fucking hitmen, and this isn’t the goddamn mafia. retard.

i also love this consult i got at 5:30pm…

hi, i’d like to call you guys for a consult. i have a xx year old man who has severe painless jaundice and weight loss. GI did an ERCP and took some biopsies. the biopsies are pending but…

WAIT STOP RIGHT THERE.

LISTEN RETARD, IF YOU DON’T KNOW IT’S CANCER, WOULD YOU WANT ME TO OPEN UP YOUR ABDOMEN, MOVE AWAY ALL OF YOUR FUCKING BOWELS, CUT OUT YOUR DUODENUM, YOUR STOMACH, YOUR SMALL BOWEL, AND YOUR PANCREAS AND TIE THAT SHIT ALL BACK TOGETHER IN SOME ABOMINABLE WAY THAT GOD NEVER INTENDED? LISTEN UP FUCKNUTS, WE DON’T NEED A WEEK TO PLAN A SURGERY, AND CANCER SURGERY OF THIS TYPE IS NOT AN EMERGENCY. AND OH BY THE WAY IT WOULD HELP TO KNOW IF THIS PATIENT WOULD ACTUALLY WANT TO HAVE SURGICAL INTERVENTION BEFORE YOU WASTE MY GODDAMN TIME AT 5:30PM.

… but it’s probably cancer. i just want you guys to come evaluate him.

HERE’S THE BEST PART:

… by the way, i’m on my way out the door right now, i’m leaving in 10 minutes. i’ll actually be on vacation for the next week and a half, but my colleague Dr. ANOTHERLOSERINTERNIST will be taking over this man’s care.

SO LET ME GET THIS STRAIGHT. YOU CONSULT ME AT 5:30PM, 30 MINUTES BEFORE MY “SHIFT” (I USUALLY WORK WELLLLLLLL PAST 6PM) IS OVER FOR A NON-EMERGENCY CONSULT, FOR A CANCER PATIENT YOU DON’T REALLY KNOW HAS CANCER, AND YOU DON’T EVEN KNOW IF THIS “CANCER” PATIENT WANTS THIS “CANCER” TAKEN OUT. AND ON TOP OF THAT YOU HAVE THE BALLS TO TELL ME YOU’RE GOING ON VACATION, LEAVING IN 10 MINUTES, AND I SHOULD TALK TO SOMEONE ELSE TOMORROW? WELL GEE ASSHOLE, I’M REALLY GLAD YOU GOT TO CHECK OFF YOUR LAST REMAINING BOX AT THE END OF YOUR FUCKING DAY, RIGHT BEFORE YOU GO ON VACATION. MEANWHILE LET ME PROCEED TO DO A FUCKING MONKEY DANCE FOR YOU SO YOU CAN FEEL GOOD ABOUT HAVING SURGERY “ONBOARD” IN CASE SHIT HITS THE FAN WHILE YOU SIP UMBRELLA DRINKS IN THE CARIBBEAN. ASSHOLE.

***

ok i got carried away with the bad part, but here’s the best part of surgery residency, especially at the VA. even though i get annoyed with the steel mercenary aspect of surgery, i’m a hypocrite because i dump all the random shit on medicine. i had some consult about a skin infection, and i was like, admit to medicine for wound care. hahahaha. it’s funny because medicine’s idea of wound care is slapping on a 4×4 piece of gauze so they wouldn’t have to look at it.

we also have a few post surgical complications, like wound infections that i would open up and drain in the ED. afterwards i ask the ED to call medicine to admit them for IV antibiotics. and they would take them! hahaha.

the best is when i call medicine to admit a patient to expedite a pre-surgery workup. these guys have no pride man, they’re like… ok we’ll take him to coordinate some labs, a colonoscopy, cardiology consult, etc. hahahaha.

***

in summary, the best and worst part of surgery residency is about pain. the worst it when you hit by it, the best is when you can dish it out. i’m sorry to dissapoint people who were expecting me to gush over some grateful patient, the time i saved a life, or came up with the correct diagnosis in some random patient no one else wants to touch. this isn’t what a doctor is about anymore. everything good about medicine is gone, and everything miserable about it is increased. it’s all just pain and the redistribution of it.

pre-2003: what’s the worst thing about q2 call? you miss half the good cases
post-2003: what’s the worst thing about q7 days off? you miss 1/7th the discharge summaries and hospital-to-hospital transfers

internship is not very pleasant. everyone talks about the steep learning curve and how i’ll learn so much this year. and surgical training is supposed to be about decisiveness, being trained to handle anything. i still feel like every situation i’m in requires me to consult the second year resident or above. like i can’t make a single move without running it by someone else first. i sort of felt like residency would be different. i still feel like a medical student in a long coat. well i did have a lot of independence on trauma and it blew up in my face often. i don’t know what’s worse, being unable to make any decisions, or making too many.  i wonder when my decisions will magically become better.

that being said, it’s a cool feeling once in a while, to be called to the OR to finish up a case or see something sweet. when i get those rare pages from the OR nurse summoning me, i feel like clark kent changing into superman as i change from my shirt and tie into scrubs.

the other day i saw an open repair of a thoracic aneurysm, where the aorta was exposed above the diaphragm, with the heart beating away in the corner of the exposed field. i still haven’t decided whether seeing something like this is worth it all; i’m not the sort to be amazed by much, or deeply passionate about any particular thing. so i’m skeptical.

anyway, by way of updates, it’s been about 9 weeks and i haven’t quit yet.

my life outside of the hospital and from work is virtually non-existent. i’m ok with that, more or less, so far.

well i just did a week of my new rotation and i can’t really complain right now.

it’s quite a luxury to go to work knowing that i don’t hate every single one of my patients. a luxury i did not have on my last rotation. it is also quite a luxury to deal with people who have insurance, because that means i don’t have to spend hours out of every working day talking with the social workers and hoping for a miracle to get some place to accept an uninsured person with TPN, PICC, gigantic open wounds, aspiration precautions, and post traumatic stress disorder. yeah that was a fun.

i also very much enjoy the fact that we have 3 patients on my service, all of whom are in the SICU. this means that the ICU team manages my patients, and therefore, i never get paged about them. this makes my weekend call pretty awesome. on saturday i rounded on my patients for no more than 15 minutes, then promptly went to sleep. woke up, got lunch, and slept some more. then rounded on my patients one more time, then went home. on sunday, i rounded on my patients for maybe 10-12 minutes, had some breakfast, went to sleep again, then went home. and for all this hard work, i get the next two weekends completely off.


one thing i notice about working here is that everyone has piss poor hygeine. not surprisingly, a pretty good amount of our patients develop post operative infections, and many end up returning back to our services. i think the ID folks here need to get their crap together.

i also managed to log my first OR case this week. yes, that’s right. this badass surgeon just sutured some skin at the end of the case. if that doesn’t get the panties dropping i don’t know what will. 2 chest tubes and one skin closing in 5 weeks of surgery residency. a few years at this rate and i might do as many procedures as an m3 on psychiatry.

going from working my ass off and having a crapload of responsibility to hardly working and basically being a medical student is pretty sweet. i think i discovered like 9 months too late that i sort of enjoy not working very hard. i still hold onto some fantasy that all of this BS will pay off in some intangible but profound way maybe like 20 years from now, but intellectually i know this is completely delusional. and yet i persist. i think people just want to say that i keep at it because i know deep down that it’s worth it and what i really want to do, but i think the truth is a lot less profound. i think i’m just too scared to stop and admit that i don’t really care about meaning, about altruism, or intellectual development. i don’t think i want to admit that i just want to watch tv and eat potato chips on a sunday afternoon for the rest of my life. and admit that deep down, living a pointless and numb life is not the great tragedy that i wish it to be, because despite my feelings of moral and intellectual superiority, i’m actually ok with achieving nothing great, ok with not helping the needy, and basically ok with just being a regular schmoe doing his own meaningless thing that no one necessarily will remember when i’m dead. i guess when i say i wish i could be happy just like all the other thoughtless schmucks out there, i’m really saying that i wish i could admit that i am one of them, instead of pathologically deluding myself and taking some perverse gain in playing the role of a troubled and depressed intellectual and/or humanitarian.

my last day on this cursed rotation. for at least 11 months anyway.


all this talk about patient autonomy is BS. once you start working on the wards, it’s all about ativan and restraints. getting nervous? ativan. talking back? ativan. complaining too often about pain? ativan. want to pull out your NG tube? ativan. trying to pull the foley? ativan. it got to the point when even i was saying to people, “i don’t like how we treat patients here. we control them medically. i want to do things the old fashioned way and talk to them.” explain things so that they aren’t as nervous, instead of masking their nervousness with drugs.

i’m also finding that i resent patients who don’t do exactly what i tell them to do. i want to yell at them to stop using so much morphine because that’s preventing them from taking a dump and getting off my patient census. get out of bed, walk, and work with PT/OT because if you don’t, it’s me who gets yelled at during signout at 6pm. why is the patient still here? because he’s a typical lazy ass leech enjoying his stay at our $1000/night hotel with free food, cable, and phone service. somehow, i doubt that these guys who live in their pickup trucks have much motivation to leave their bed and free cable just to go back to sleeping in their car.

i’m finding i need to fight the tendency to become punitive with my idiotic patients. i know it’s not pleasant to have tubes in every orifice, but if it’s what we need to help you get better, stop being dumb and keep that shit in there! i have this dumbass who aspirates every time he eats anything, so i put in a dobhoff tube for tube feeding. this moron pulled the DHT probably more than 5 times during the time i was there. he’s constantly begging to eat something by mouth. hey listen dude, we already explained to you that if you eat anything through your mouth you WILL choke and die. if you keep pulling the DHT, we can’t feed you, and you will starve. it’s funny, when the choices are starve/choke/die vs keep a thin tube coming out of your nose, this jerk off chooses the former every chance he gets. i was pretty damn tempted to say screw it and let him starve for a day.

dumbass patients create exponentially more work for me. just think… if this asshole didn’t pull his tube 3 times, i wouldn’t have had to write 3 orders to put in a tube, 3 orders for a stat KUB, look at the xray 3 times to check the placement, or tell the nurses to pull back on the tube just a little bit… and get another KUB, look at more xrays, etc. all this fucking work to feed some loser. if i ruled the world, noncompliant patients like this would be kicked out of the hospital, and if they choked and died, that would be their damn fault, and it wouldn’t be my responsibility to baby this asshole like a little child. whatever happened to personal responsibility? he’s not crazy, he’s just stupid. he’s free to make foolish decisions. why should i prevent that? let’s face it, the vast majority of the world makes dumb decisions and we let them do it. he’s an adult. a dumb one, but i think that still counts.

and let me just say, that i think it’s bullshit that some idiot who shoots himself with a shotgun (i’m not entirely sure how he managed to do that), has to be coddled back to health while watching cable tv and sitting on his ass while nurses and doctors have to change his wound dressings several times everyday, wipe his ass, and record the amount of urine he makes every 8 hours. you think america doesn’t take care of the uninsured in this country? then how do you explain why this redneck asshole with no insurance is getting world class healthcare after trying to kill himself? how do you explain how someone with no insurance has been staying at my hospital for 90 days getting huge operations, skin grafts, tube feeds, TPN, cable tv, and all that shit? if we didn’t treat uninsured people, i wouldn’t have spent all those nights smelling all the rank ass shit coming out of someone’s bowel fistula, obsessing over how much potassium she has in her blood, how many calories she’s getting in her TPN, how much urine she’s made, how well she is working with physical therapy, what types of stepdown places will take her without insurance, or write a note on her (non)progress for 30 god damn days. hell, i wouldn’t have had to deal with over half of these uninsured dipshits who drink like 20 shots and play chicken with a tree on the side of the road. i would have had time to eat at least once a day, actually take a piss more frequently than every 12 hours, and had time to read and actually learn something other than the doses of morphine, dilaudid, and fentanyl.

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