Cigarettes & Alcohol

No one was coming for his heart or his liver, and it was clear why. No sooner had we taken a scalpel to the skin over his abdomen…my attending starting down by the pubis while I started from up under the xiphoid…we met at the navel…we got through the even poorer protoplasm below it and entered into his peritoneum to find a belly full of ascites fluid. His bowels, thin, pale and filled with air and succus, bobbed up to the surface of the yellow fluid. I placed a suction device deep into his abdomen and watched as the fluid drained out, much like it would from a bathtub with the drain pulled. Liters were drained and what remained were the sad contents of his jaundiced abdomen. The now visible liver did not glisten as expected, and it certainly wasn’t its usual color. It was cobblestoned and knobby, cirrhotic, tortured by this man’s very close and very daily relationship with alcohol. No. We wouldn’t be touching that. Or his pancreas, which was nearly calcified through and through likely from several bouts of alcoholic pancreatitis. His blood vessels, conduits which should be smooth and elastic, were crunchy...hardened by his slavery to cigarettes. Attempts to cannulate them revealed rinds and rinds of yellow, cheesy, calcified atheroschlerotic plaque, filling in the lumen, obstructing blood flow. It was a wonder this man’s legs were getting any blood at all.

We were only there for his kidneys. Kidneys that were risky to take, having come from someone in such poor shape. Kidneys that someone in a nearby state desperately needed. Kidneys that this man’s wife had graciously signed the consent form to donate despite the grief she must have been feeling after loosing a husband who, just three weeks prior, had decided to give up both cigarettes and alcohol. A hypertensive hemorrhagic stroke robbed him of his chance to try out his new life. He was only 51.

Far too young if you ask me.

The best of both worlds

My usual week at the county hospital, a hospital I spend much of my time in as a surgical resident, involves a number of things that may seem overwhelming to one who might work a standard 9 to 5 office job (particularly when that office job rarely involves blood, pus or excrement of any kind). Things like…

…a work day that starts around 5 AM.
…a work day that ends anywhere from 5 PM that same day to noon the day after.¹
…an average of 80 hours a week at work and four days off a month.
…a fair amount of sleep deprivation due to that which is listed above
…an even fairer amount of blood, pus, excrement (and a myriad of other bodily fluids for that matter).
…at least once a week, no less than one categorically drunken, drugged-out patient either spitting at me or, equally as charming, calling me a bitch.²
…patient upon patient with bullet wound after bullet wound…with bullets that sometimes, oftentimes just by luck, have just grazed the skin…others that have penetrated through the sternum right into the left ventricle of the heart…still others that have miraculously managed to hit a rib anteriorly, ride it all the way posteriorly, and lodge themselves right by the spinal cord without any injury to any organ system whatsoever. Not surprisingly, the latter is the least common of the three listed scenarios. And sadly, there are infinitely more scenarios.
…swollen ankles from hours on end of standing in the operating room.
…ultimately, and what makes me do it, the satisfaction of diagnosing an operable disease, and performing the necessary procedure to take care of the patient (regardless of whether he or she spat at me or not). (And usually, even the spitters are grateful once the anesthesia has worn off.)

It goes without saying that the job is somewhat demanding. And after three solid years of working 80 hours a week, I was very much looking forward to the “break” that a stint of research would give me. Last July I signed on for a two-year leave from my usual clinical schedule to do breast cancer research. Cancer, for reasons near and dear to my heart, is something I’ve had an interest in helping abolish since early on in my medical education. Surgery can be an effective cure, and it’s certainly very satisfying when it is…but oftentimes it’s not. So looking for the reasons for this and finding ways to anticipate and prevent them, is very exciting to be a part of. The breast cancer research community as a whole, a community that spans the entire globe, is at a very pivotal point right now…and participating in it all is fulfilling in a way that is much different from my usual day at the hospital.

Plus! The added perks of a research job are things like…
…a work day that starts around 9 AM.
…a work day that ends anywhere from 5 PM to 7PM.
…an average of 40 hours a week, evenings and weekends off.
…a fair amount of sleep.
…absolutely no blood, pus, or excrement.
…a sheer lack of obscenities being screamed at me by patients
…no bullets
…ankles that do not protest when I attempt to zip up my boots!
…time to do other things…like visit friends and family, dance, and write this blog!

This is temporary…as I’ll go back to my usual clinical schedule in June of 2008. And I suspect that by then, I’ll be ready to jump back in to the chaos of it all. Afterall, I already miss working closely with individual patients and I certainly miss operating. And, sometimes, strangely enough, being screamed at, spit at, or called something profane at 3 AM by a perfect stranger, is more awakening than a stiff cup of coffee!

1. Yes, this means some of my shifts, usually around one to two a week, hover around 30 hours long.
2. To which I usually reply, “That’s ‘Dr. Bitch’ to you, Sir.”

In sickness and in health, with one itty bitty testy exception

A compendium of the most recent health issues I’ve been asked to address and/or examine by friends and family who I (for the most part and under normal circumstances) care greatly about:

Dochechka’s healing surgical incision. (Looks lovely, by the way.)

Abuelito’s lower back sebaceous cyst. (Not quite as lovely. Charming, I think, would be more fitting.)

Vinja’s through-and-through dog bite to the left ear. (Not kidding.) (I suppose that’s what he gets for ignoring all of my persistent medical advice to stop hanging bacon from his earlobes.)

Blossom’s local anesthetic needs for a very large tattoo. (She wanted to know if I considered it safe for her friend (a dentist) to do the anesthesia on her back. Considering there are no teeth on her back, I advised against this.) (Also not kidding.)

[Will remain unnamed]’s scrotal abscess. (I SO wish I was kidding.) (Thank goodness this consultation was solicited from long distance via the telephone. My advice to this individual: Uhhh…you should go see a doctor for that.)

This last encounter has inspired what will be the caveat to all future consultations by loved ones and acquaintances. I hate to have to do this, gentlemen, but from here on out, when someone asks for my advice, my agreement will require the acceptance of the following terms: Keep your boils, your scrotums, and your scrotal boils away from me. Sorry, ladies, I suppose to be fair, you’ll have to keep your ovaries away from me too.

In other non-scrotal news: I go to Japan tomorrow! Yippee!!

In the name of Academia

Werner Herzog (a German film maker who is particularly nutty in a deliciously entertaining sort of way), recently said “Academia is completely devoid of all human pathos…and should thus be avoided at all costs.” This made me chuckle heartily at the time because I could certainly think of more than a handful of academians in my med school experience and my surgical training to whom this so completely applies. (Still can.) They make learning unfun. But for every tight-assed bore out there, there are multiple more charismatic and personable academians. And I like to think that, in the medical world, we have the Charismatics in Academia to thank for cures to cancer, successful vaccinations, and among many other things, we hope, the training of good surgeons.

At least this is what I tell myself in the late hours of the night and the wee dark hours of the morning, when I am up reading and studying, twitching from a noxious combination of nearly lethal doses of caffeine and surgical trivia. This has been my plight for the last several weeks, all in preparation for the annual American board of surgery in-training exam. Every general surgery resident in the country (even those on their research hiatus like myself) has to take this exam. And it’s always the last Saturday of January. Which, just in case you’re too appropriately sleepy at this small hour of the morning to realize, is tomorrow.

So, permit me this pause in obnoxiousness just for today. Wish me luck. Think good surgical thoughts for me tomorrow morning between the hours of 8am and 1pm PST. And we shall return to the usual, and only slightly less caffeinated, shenanigans post-exam.

Because I do so enjoy performing rectal exams...

I hesitate, when I’ve just met someone, to tell him or her that I’m a physician. Even when I am asked flat out what I do for a living. Because the response I tend to get usually involves a look of surprise (which, in principle, could be taken as either a compliment or an insult*) and a verbal response somewhere in the ballpark of, “Wow, uhhh…you must be, like, really smart then, huh?”**

No. Actually. Dumb as a box of hair. I’ve just risen to the top by honing my blow job skills and then demonstrating them on all the right people.

I usually almost immediately regret saying this out loud. Not because it doesn’t amuse me. It does. (Every time.) (Have I mentioned that my middle name is Crass?) But only because if I had to say it in the first place…the conversation was in dire straights from the get-go. I mean, honestly, what kind of response does a question like that deserve anyway?

But sometimes, I encounter a person, as I did recently, who is genuinely and wholeheartedly interested in knowing about my job. And by genuinely and wholeheartedly interested I mean unequivocally obsessed with ER, Grey’s Anatomy, Scrubs, Nip Tuck, and all the clever, and exceptionally good looking forensic pathologists (of which, in real life, there are NONE) on all those CSI shows. And they want details. Details like: What kinds of surgeries do I do? Doesn’t all the blood make me sick? How do I handle all the death? Do all the doctors really make hot monkey love in the dustbin closet or in an empty ICU bed like they do on Grey’s Anatomy? How did I decide to go into surgery anyway?

I always enjoy giving the answer to the last question first. I tell them about the real life story of me, in med school, in the impressionable days of my fourth year. I was doing a surgical pathology rotation*** and the attending I was working alongside was processing an abdominoperineal resection specimen. He removed the fresh slab of tissue from the bucket, still warm from having just been resected from it’s owner, and examined the hard, circumferential mass of rectal cancer within it. While he did the standard pathological assessment, he and I nonchalantly chatted away, much in the same way one does with their hairdresser while getting their hair cut. We touched on topics like why I had chosen to apply for a general surgery residency and why he, years ago, chose a profession in pathology. Now, forget for a moment that my attending was clearly NOT cutting my hair, but instead processing a specimen that was inclusive of a patient’s rectum, their rectal cancer, and their anus complete with a small cuff of skin and one stray, stubborn hemorrhoid. Let’s just focus on the fact that it was at this moment he expressed that his reasons for going into the non-clinical field of pathology (as opposed to the clinical field of surgery) were primarily because he never wanted to have to do another rectal exam**** again ever in his life. I paused for a moment as I watched him stretch the specimen out in front of him, holding it in the way one would a telescope, the hairy anus end within inches of his eyes. Then I said, “Riiiiiiiiight. So how did that work out for ya?”

It was that moment that confirmed why I’d much rather work with patients, real live people, than just their tissue. Mostly so that, years later, some obnoxious medical student couldn’t just waltz into my office and totally debunk my reasons for who I’d become.

If I still have an audience by the end of this story, which this particular time I did, then I give them a real treat. I tell them that, yes… [Cue 70’s porno music here.] In the small, dark, cramped, sweaty corners of the hospital…it’s all doctor on doctor, doctor on nurse, nurse on nurse, medical student on doctor, nurse on medical student. TWENTY. FOUR. SEVEN. It’s a proper brothel for all intensive purposes. Which means that it really is like Grey’s Anatomy. Cuz Lord knows all those emesis basins and colostomies just make us all SO insuppressibly hot.

* For example. A Complimentary look of surprise, if it had a mouth, would say: “My goodness, you look so young to be a doctor!” whereas the Insulting look of surprise would say: “You? You’re a doctor? Yeah…and I’m the fairy godmother.” I’ve been on the receiving end of both.
** I know. Can you believe anyone would really say that? Not to be sexist in any way, but seriously, only men have ever said this to me. Women tend to say something more along the lines of “You GO girl!”
*** In Surgical Pathology, the pathologist examines the gross (visible to the naked eye) and the microscopic appearance of all the specimens that come out of the OR: the lump of breast cancer that came out of a patient, the ruptured appendix that came out of another, etc.
****Meaning a Digital Rectal Exam performed on a live person to check for things like prostate or rectal cancer.

Doesn't the month of April make YOU horny?

No? It doesn’t? Yes it does. Admit it.

I have reason to believe that April makes everyone, but especially Catholics, horny.

Now, in practice, I tend to be more of an evidence-based kinda gal when forming opinions or making decisions. Everyone knows that anecdotal evidence is biased and inaccurate. Por ejemplo…

Evidence based: I generally don’t drink carbonated beverages because studies have shown that the caffeine and phosphorus in these drinks have a deleterious effect on calcium absorption, contributing to, among other things, osteoporosis.

Anecdotally based: I don’t like to drink soda because I think it makes my ass fatter than it already is. (Which it does.) (But that’s not the point here.)

The point is that the former is fact-based. The latter just depends on which mirror I’m looking at. (And for the record, in those moments of weakness when I want to justify just one soda, I simply slip down to my bedroom where our full length mirror tells me sweet, sweet lies.)

All digressions aside, I have evidence to believe, based on a Case Study, n=7, performed at my reputable and highly academic institution (AKA, my house), that April, along with it’s bountiful showers, brings with it the overwhelming urge to do the nasty. Without protection (hence the Catholics being implicated here). Which then results in impregnation. And thus, the birth of a child, the fruit of one’s loins, say…in January. And thus, the fact that EVERY-FRIGGIN’-BODY’S BIRTHDAY IS IN JANUARY. Ok. Not everybody’s. Just Abuelito’s. Abuelita’s. The Love Muscle’s. Captain Organico’s. The Brit’s. Daddio’s. And Homeslice’s. (I’d like to point out that some of the above are NOT the offspring of latinos (rumored to be particularly amorous…I believe it is said in certain circles that we “hump like bunnies”) and that this n of 7 is made up of people from all over the world. Making it a rigorous, and I feel, more accurate Case Study.)

So there you have it. Proof. That April is some sort of provocative aphrodisiac in and of itself. I, for one, will be using birth control. But just beware. Without protection, you’re forever damning the rest of us to bankruptcy during the month of January. (And after Christmas, when we’re already broke as it is.)

Horny (Catholic) bastards.

Battle of the Baby vs. Cell Phone

This morning we had our weekly Tumor Board meeting, a multidisciplinary get together where we gather to discuss difficult and challenging cases. Or, simply put, it's a chance for all of the great, academic minds of radiation oncology, hematology oncology, pathology, and surgical oncology to spout and pontificate, some more self-righteously than others, on how to deal with the unfortunate 45 year old woman who has two different histologic types of breast cancer in opposite quadrants of the same breast. What to do? Two separate lumpectomies with radiation? Or Mastectomy? Over the course of each meeting, I usually learn a thing (or five)...and in the very least, I ALWAYS enjoy watching the battle of the minds. It’s not unlike watching a WWF wrestling match…only in place of the greased-up, steroid-fortified body builders, picture the wrestlers as pasty, white, bifocaled, bow-tied nerds with massive egos. Great fun.

So today started out like any other Tumor Board…Medical Doctors, Surgeons, Nurse Practitioners, Social Workers, Statisticians, Pathologists, Radiologists, Medical Students, Residents. We all filed in. To minimize the distractions, everyone traditionally turns their pagers and cell phones to vibrate as they cross the threshold. Today was seemingly no different. That is, until Baby came in…perched on the hip of his mom, one of the nurses that works in the office.

Now, let me just say…I’m not a huge fan of babies in meetings. Ok. I’m not a small fan of them either. It’s not that I’m anti-baby, but, in a meeting such as this, it’s just not appropriate. They tend to coo and gurgle (or worse, scream and cry). And if they don’t do that themselves, they tend to illicit coos and gurgles (and goobie goobie yummy wummy shmoopie poopie noises) from all the XX’s in the room. Either way, they’re a distraction. And, frankly, Mom is usually so preoccupied with making sure Baby is sufficiently entertained in the all-adult meeting to glean anything from or contribute anything meaningful to the meeting. (Though, I do believe Mommies have bionic auditory capabilities that may counterbalance the distraction of having Baby with them. Being currently equipped with a womb that is being hormonally maintained in a state that is unsuitable for baby growing, aka being on birth control pills and thus NOT presently a Mommy, I cannot comment on the bionic mommy ears.) (And, for the record, I do understand that things happen…babysitters cancel, or babysitters get stuck in traffic, or babysitters get eaten by the dog. I get it. So we roll with the punches.)

So, enter Mom with Baby. To Baby’s credit, he seemed perfectly pacified by his pacifier and, frankly, was sitting more quietly than most of the adults in the room. Just when things settled down and the meeting began, Mom shifted in her seat and, in doing so, accidentally pressed what was likely the belly button of some soft wooly baby toy stored within her baby bag. A muffled nursery rhyme tune poured into the room from within the bag. Mom was mortified. But the damage was done. The toy just needed to play out its song. About 15 seconds into the nursery rhyme, meeting going on unimpeded, Dr. Snooty McProperPants (one of the particularly self-righteous MD’s in the room) leaned over to the already embarrassed mom and, without even the slightest effort to cover up her feigned attempt to look unsmug, said “Is there something playing? Could you make it stop?"

Mom shrugged helplessly. Dr. Snooty McProperPants peered condescendingly down over her designer glasses at the annoying child and his musical baby bag. The nursery rhyme ended seconds later. Baby remained seated, oblivious, content, and quiet on Mom’s lap. Meanwhile, at the front of the room, two docs were verbally duking it out over the fact that there isn’t sufficient data to support recommending a treatment that is not currently standard of care for the woman with two different breast cancers in the same breast…

Then all of a sudden, and I love this part, a shrill and meeting-interrupting cell phone ringtone erupts from the embarrasingly expensive bag of none other than Dr. Snooty McProperPants. Let’s overlook the fact that it was a bad, tinkly, dissonant version of Bach (one that I hardly think he’d approve of) and just bask in the sweet, sweet ironic glory of the fact that it was disturbingly loud. Louder than the baby. Louder than the baby toy. Dr. McProperPants scrambled to find her phone. Twenty long seconds later, she found it. And ANSWERED IT…and proceeded to have a not-so-hushed, but entirely snooty and quite-the-opposite-of-proper conversation, apparently with her lunch date, on where to meet for lunch.

Mom peered over the top of Baby’s head at Dr. Snooty McProperPants. I just wish she would have said “Could you make it stop?”

I believe we should chalk one up for the baby?