Flatus and Stool

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.