First Day of Neurology

It's been four weeks, so it's time for another rotation: neurology. I can't say I am looking forward to this rotation since I do not find neurology -- or even neuroscience -- fascinating. Any time I hear words like "thalamus" or "amygdala" I seem to zone out of the conversation, so I have to watch myself for the next month.

Neurology might be particularly agonizing because one of my surgical subspecialty electives was neurosurgery, and so I had first-hand experience (and enjoyment) with the surgical side of solving neurologic problems. Unfortunately, the medical side of neuro problems is essentially limited to diagnosis, since not much can be done medically for neurologic problems.

I am also a little worried, since I tend to be susceptible to neurologic conditions when it comes to my hypochondria. After meeting our three myasthenia gravis patients today, I am already a little self-conscious about my possibly drooping eyelids.

This will be a long 4 weeks, now for more than one reason.

Residency Applications

The time has come to apply for residency. Which means I will soon be graduating medical school ... and soon be "a doctor". I have to say this moment crept up on me a little quicker than expected. It is now time to write another personal statement, harass more faculty for letters of recommendation, and make a laundry list of my accomplishments. I am starting to depise this process since I feel like I've been doing it non-stop year for the past several years.

Back to residency applications, since the process is a little different from college or medical school applications, I shall describe the steps here in brief:

Step 1: You first submit your filled-out application to a centralized service, who then sends it to all the residency programs you've selected. The earliest you can submit is September 1, and as usual, the earlier the better (I just realized Sept 1 is quickly approaching).

Step 2: Programs may then choose to interview you, and interview season usually runs November to February. Only if you get interviews, may you proceed to the next step. If not, please start over -- next year.

Step 3: This is when it gets a little hairy for most people (at least non-medical people). At this point in the process, applicants rank the programs they interviewed at; in other words, they state that their #1 choice is Program X, #2 is Program Y, etc. Similarly, the programs go through and rank all the applicants they interviewed.

Both of these lists are then submitted to that same centralized service again and are run through a computer, which takes the lists and matches every applicant with a program. Theoretically it creates an optimal list of matches (matching applicants and programs), whereby no two people could be happier if they were to switch with each other.

Match Day: This is the day when people find out where they've matched. It takes place in March, and it is a significant day in the lives of every medical students, since it is when they find out where they've been assigned for the next several years. For most people it is a day of happiness. On the other hand, don't like where you're going? Tough.

. . .

Anyway, September 1st is quickly approaching, which really means I should finish preparing my application.

TB for all

One of our patients was just diagnosed with tuberculosis.

It's not a big deal, except that TB is a serious public health concern. Since this disease is essentially non-existent in most industrialized countries (we see it because there is a large immigrant and Mexican population at our hospital), public health officials want to ensure that all TB patients are being actively treated. In an effort to further minimize its spread to others, they also try to make sure people in close proximity to the patient are protected from the disease.

Specifically this means that when a patient with TB is discharged home, they will be visited weekly by nurses who force them to take their medications, and the patient's family will have to take TB medications too.

So when we were ready to discharge home our patient, we had the TB Control people get in touch with her family to get them involved with the plan ... only to find out the entire family already has TB!

It doesn't get easier than that! That's certainly one way to avoid dealing with the TB Control people. And what do you know ... a county patient made things easy for once!

Struggling with the Dead

We already have a huge patient census (9 ICU patients!), which is miserable enough on its own. But who would have thought that out of all our patients, it's our brain dead patients that cause the most trouble. You would think these two patients -- these two motionless bodies that, for all intents and purposes, are dead -- would be the easiest to take care of. But no.

As each patient has family that will not accept the fact that these patients' brains are technically dead (perfusion studies have shown that their brains are not receiving blood flow), they refuse to allow us to perform a "terminal extubation" ... meaning they won't let us disconnect the ventilator from the patient so that the patient may die.

At first we thought we could invoke California state law, which mandates that once a patient is declared brain dead, terminal extubation must be performed within 12 hours. Unfortunately we couldn't take advantage of that law because we could not just yet declare them brain dead. And what was the reason for that? Because a patient cannot be declared brain dead until all of their electrolyte abnormalities are normalized.

So ... in an effort to declare these patients brain dead, we are busy correcting their low sodium, elevated blood sugars, and elevated creatinine. Which means we are giving our dead patients saline, insulin, and (get this) dialysis. Even better, one of them has an anemia, so he is about to be transfused with some red cells.

I don't want to come off as insensitive, since I know this must be a hard situation for any family, but there comes a point when evidence makes it clear the patient will never recover. I guess it's easy for me to think like this, since it isn't my loved one that is affected.

In any case, it's quite a hassle taking care of our dead patients.

(With all that said, I hope someone from above doesn't strike down upon me with great vengeance and furious anger.)

More Interactions with ENT

One of our patients who was recently trached started bleeding from her trach site. We thus called back ENT -- who placed the trach and wants responsibility for making any adjustments to it -- to investigate the bleeding, identify its source, and fix it. Eager to get involved with any procedure (I swear, surgery is my true calling) I offered to help them, and they gladly accepted.

So for more than an hour I worked with the two ENT residents at the bedside, as they cauterized the hell out of one fat goiter (large thyroid gland) that was causing all the bleeding. Assisting them was interesting, and at the end they asked if I would help clean up. I had no problem helping them clean up the large mess that they had created, which entailed bloody 4x4's, empty suture packages, and dirty surgical towels scattered on and around the patient's bed, as long as it was just that -- helping.

Once I agreed they promptly walked out of the room and left me to clean up the mess alone ... but not without first making me aware of a "sharp" (needle) they had lost somewhere on the bed!

Thanks asshole! First, didn't your momma teach you to clean your own fucking mess? Next, if you are going to make a medical student clean up your crap, at least ask your own medical student to clean up your crap -- not one from another service. And finally, you're an even bigger asshole for making me clean up your mess after you conveniently lost a sharp that I will probably "find" by accidentally sticking my finger into.

I've gotta say, after my last encounter, my track record with ENT is 0 and 2.

Grand Rounds

It's that time again. You can find them at Inside Surgery this week.