blahblahblhblahbl-You-Have-Cancer-blahblahblahblahblahblahblahbalh

We learn early on in medical school that there are certain phrases that cause a great deal of anxiety within the minds of our patients. Once uttered, the mind will fall into an almost mystic ileus, unable to process anything further.

“Your son/daughter/brother/sister/father/mother is dead”
“You have cancer”
“You have genital warts”
and so on and so forth

This isn’t news to anyone. But what they didn’t teach us in medical school, was the wide variety of responses to crushing news, and the resultant effect it has on the psyche of the physicians in charge of the care of these patients.

Last week, I had the dreaded responsibilty of telling two of my patients they had cancer. Not just cancer, but the “you-have-months-to-live” cancer. Both situations were suboptimal. Both patients had been jerked around by the system, misdiagnosed, misinformed. When they finally were referred to our team, one had been diagnosed with pancreatic cancer (essentially a death sentence) with diffuse metastasis throughout his abdomen and secondary small bowel obstruction. The other had been diagnosed with colon cancer with metastasis to the liver (also a poor prognosis).

Patient 1 was an absolute delight to treat. Pleasant, optimistic and incredibly understanding despite the fact that the medical system had failed him. Patient 2 was the complete opposite. Abrasive, rude, arrogant and high maintenance. Pretty much the worst traits a human can possess. Also, his wife was an idiot and equally as abrasive.

I’ve always tried to treat my patients equally, no matter what their race, income, education or degree of malodorousness. I’m usually pretty good at that, leaving prejudice at the door that is. But the amount of counter-transference I experienced the past week was shocking.

I felt incredibly sympathetic (empathetic?) for patient 1. I felt genuine sadness for his wife, his kids, and for the man himself. And I believe it showed – through the tone of my voice, my body language, and the overall length of time i spent every morning with him at his bedside. On the other hand, patient 2 filled me with anger and resentment. And it showed too, I’m sure, despite my most earnest of efforts.

Often times, 4 of us would enter patient 2′s room. The moment he opened his mouth, the charge nurse would leave. Then his wife would speak and a resident would leave. Then 2 more minutes would pass and another resident would leave. Finally, I would have to excuse myself, lest the throbbing blood vessel on my forehead rupture. I would find my team exasperated, frustrated and insulted… fuming in the hallway at the injustice that they had just endured at the hands of such an ungrateful patient.

Both patients have since been transferred from our service, which has allowed me to think. And this is my shameful realization.

Disease chooses its patients. Patients never choose to be sick. Patients never choose to die. It is unfair, it is often abrupt and it is always life changing. So why SHOULDN’T they get to choose to be upset and rude and abrasive? They have just lost all the control they believed they once had over their own life. They WILL die and there isn’t a damn thing they can do about it. Who wouldn’t have a difficult time coping with that?

My cancer patients are important. They are not any more important than any of the other sick people, but they are important because many of them will die – soon. They can choose to be pleasant or they can choose to be pricks, I can’t control that. But for damn sure, I should be able to treat them with patience and compassion. Afterall, what do I really have to be angry about? This is what I signed up for and it should be an honor to be a part of their lives in the end stages. No, it is an honor.

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Crappy consults.

The bane of every physician’s existence is the crappy consult. Especially when they happen at 3:30 in the morning, especially when the patient has been sitting in Emerg since 3:30 in the afternoon, and especially when the consulting physician gets the unit clerk to call in the consult.

These are a few of the gems from the past month.

1. A consult by my attending to a urologist. And I quote:

“can’t pee. flomax don’t work.”

2. emerg doc: “i have a 76 yo retired surgeon for you to see, he had some RLQ abdominal pain that has now resolved spontaneously, and a normal CT.”
m: “ok, and what else?”
e: “ya thats it, but he’s a retired orthopedic surgeon”
m: “but he doesn’t have pain anymore?”
e: “no, but he’s a retired surgeon, so you should probably call your staff”

3. unit clerk: “hi, consult on unit 71″
*silence*
m: “hello?”
uc: “yes?”
m: “you have a consult?”
uc: “yes, here on unit 71″
m: “what are you consulting about?”
uc: “i dont know, i’m the unit clerk, let me get the nurse”
RN: “hello?”
m: “ya, go ahead”
RN: “who is this?”
m: “this is surgery”
RN: “oh! how can i help you?”
m: “you had a consult?”
RN: “yes, the unit clerk has the details, hold on let me get her.”

4. ED: “We have a guy with an ileus of some sort, dilated loops of bowel all the way to the rectum”
–on exam–
LARGE, obstructing mass in the rectum found on DRE.

5. ED: “lots of abdo pain, change in bowel habits, exam is normal.”
–on exam– (as per the 2nd year medical student)
non-reducible, tender, possibly incarcerated, right inguinal hernia, TEN centimeters in diameter.

‘sigh’

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Reason for Nursing #1

People are haters, and somewhere along the way,  people started to hate on the profession of nursing. And by people, I mean asians.

A warped mentality exists, in asian households, that if you are not an engineer, astronaut or grade 8 math olympiad champion, you have let the team (family) down. This irritates me greatly because the extension of this disappointment transforms into a condescension for “lesser” professions, such as nursing. A result of this ignorance is that the younger generations feel that such professions are ‘below’ them and don’t seriously consider them as viable career choices, which I feel is incredibly unfortunate.

So, I’m going to talk about nursing. And I’m going to talk about why it’s a great profession and why you should all quit your jobs and become nurses.

I have just finished my rotation on the Neonatal Intensive Care Unit (NICU) service. This is how my day goes:

Blast through my  morning rounds on the babies. I flip, poke and prod them, listen to their hearts, their lungs, check their meds, scribble an illegible note in their chart and then check the clock to make sure I haven’t taken more than the alotted 6.5 minutes.. and move on. Then we round with the team of docs for another 2098325 hours. Next to no patient contact, hell, I didn’t get to hold a baby once!

Meanwhile, the nurses did everything else, from soothing the kids after I had made them cry, to changing their dressings, tubes and diapers – essentially acting as stand-in mothers while their real moms recovered.

I often found myself looking enviously over at the nurses rocking their 5lb patients to sleep, wondering where people got off bashing the profession. The ‘healing’ that doctors do would be non-existant without the tireless effort of their nurses.

And on a totally unrelated note,

Go Canada Go

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Deep Breath

I am procrastinating. My plane leaves for Halifax in a couple hours but instead of packing, I’m thinking about the past couple of weeks. Having traversed 90% of the country for surgery interviews, I’m exhausted. I’m tired of flying, I’m tired of changing in airplane washrooms, of brushing my teeth in airports, of dropping hundreds of dollars on cab rides to and from airports, hotels and hospitals.

I’m tired of selling myself and tired of listening to programs sell themselves to me. Why do I want to be a surgeon? I have a scripted answer. It used to seem real, but I’ve been asked this question so many times that I can give my answer with my eyes closed.. verbatim. Is that what this is all about?

These are the most important interviews in my life (thus far), the pinnacle of all my years of post-graduate education and yet, it seems anti-climatic to me now. Incredibly stressful still, but simultaneously lackluster.

Sitting for my interviews at the University of Toronto last week, me and a room of applicants listened to the program directors present their case as to why Toronto was the biggest, bestest and the most deserving of the finest applicants. Over an hour of propaganda, but no different from any other program.

And as I sat there daydreaming, I couldn’t help but ask myself a simple question. Is this why I dreamed of being a doctor for all of those years? To play the game?

Medicine used to be a field that seemed so pure to me, so noble, so simple. I’m sure it still can be, I just needed to realize that it’s up to me to make it so, because certain aspects (not all) of this profession for damn sure aren’t.

And with that, I’m off to Dalhousie and Memorial University for some sweet, sweet lobster. Pray for me homies!

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Why I believe the Alberta Children’s Hospital is the nicest hospital in the country.

I’ve had the opportunity to work in many of the major hospitals in Canada. Over the next few weeks, I’ll tour the remaining major centres. But for now, ACH takes the cake. Here’s why.

Huge-ass (and clean) washrooms.

wide-ass hallways with the kid's art work displayed throughout.

a cafeteria equipped with a stage for patient performances. Apparently first-run movies can also be played here. Note the aquarium under the staircase.

exterior designed by the kiddies themselves. Those light posts also change all sorts of colors

HEATED garages. Will save your life in the Calgary winters.

The following pictures are jacked. For fear of being fired, I was unable to take my own pictures when real patients were in the shot.

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cafeteria with a breath-taking view of the Rocky Mountains

when the ER looks like this, everything is just less scary.

Patient rooms with a built-in bed for parents to stay the night.

all sorts of activity rooms for the sick kids. This is a sun-room for oncology patients.

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My issue with affirmation and encouragement

I’m not the biggest American Idol fan but whenever I do watch it, I am utterly amazed at the blatant lack of singing ability that people possess. However, what amazes me even more are the countless contestants that break into tears and cry when the judges tell them they suck, as if its any surprise at all.

“I know i can sing. All my friends and family say I have a voice like Mariah or Whitney. My singing coach says I have the voice of an angel.”

Then they go on to cuss out the judges and make a fool of themselves.

I feel like this is a much bigger issue than a simple singing contest. How are people to better themselves when the people closest to them are too stupid or too consumed by liberalism to discipline or to offer constructive criticism? Whatever happened to the concept of ‘tough love’?

I don’t know how many parents I’ve encountered that applaud their child’s C and D averages because he’s “doing his best”, when in actuality, he’s smoking weed with his buddies and getting suspended every couple of months. Or how many teachers I’ve talked to who complain about their inability to discipline or fail undeserving students because the school board doesn’t want to hurt anyone’s feelings.

Little Jonny wants to be a doctor? Let’s all celebrate and have a party because he has BIG dreams and works towards these dreams by watching Gray’s Anatomy every week. Gimme a break, this culture of entitlement, laziness and instilling false sense of confidence is going to destroy the youth of our generation.

There is a place for affirmation, encouragement and positive reinforcement – when someone has ACHIEVED. If his absolute best is a C, then hell, I’ll give your son a pat on his back for you, but I am sick of parents and teachers that feel that they are ‘protecting’ their kids from the big bad rejection of the real world when in reality they’re cutting their legs from under them.

Now that’s what I’m talking about.

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I rarely have the time to read for fun, but this is a must read.

The honor of worrying – of caring, of easing suffering, of being present – may be our most important task, not only as friends but as physicians, too.

And when we are finally capable of that, we will have become true healers.

- Final Exam, Pauline Chen.

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KN

I’ve been thinking lately about the psychiatry rotation I was on for 6 weeks back in the summer and I found this little excerpt. I think it’s good practice for me to remember my patients. What I learned from them, how they affected me, and they made me a better doctor, and hopefully a better person. Maybe even how I can pray for them. I will try to make this more of a habit.

“The weird thing is that most of the pts assigned to me are little old ladies in their 70′s and 80′s and 90′s suffering from depression, bipolar and dementia. On my first day I looked at the slate and groaned since old patients with dementia and depression are the least exciting and the most difficult to treat. Everyone felt for me, my classmates, the nursing staff, even my preceptor felt bad for me.

Over the past six weeks I have learned to embrace all my little old ladies to the point where i see them as my own grandmothers. Sounds lame I know, but its true and I laugh everytime I think about them – grumpy old , super depressed ladies who just want to be left alone, getting bothered every morning by this goofy kid who jokes around and laughs at his own jokes (because they haven’t smiled in a month).

IP with the brain tumor and the toothless smile. GH with the intractable depression who upon discharge, went home and broke her hip, and who will likely never leave the hospital again… and MJ, with the overbearing/useless daughter who used the hospital as a babysitting service despite her mother’s great response to treatment.

Apart from my surgery block, I still find those six weeks some of the best weeks I had in clerkship. Strange now that I think about it since I went in with such a poor attitude. I feel like there is a lesson to take from this somewhere.”

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These days.

Currently at UBC for vascular surgery.

my most memorable patient will be this man.
a 60-70 something year old who underwent an abdominal aortic aneurysm (AAA) repair on my first day. The procedure went well. Then on the first post-op day he threw a clot to his left leg and we had to bypass his femoral. On the third day, he threw a clot to his brain and he stroked.

We are 5 days out now and he has since gone into renal and liver failure, has had an MI (heart attack), infarcted his spleen and his spinal cord leading to paraplegia (paralysis of his legs) and is currently in ARDS (acute respiratory distress).

If my pager goes off tonight it’ll likely be announcing his coding on the unit.

I think the response of the team this morning sums up best how I’m feeling.

jr resident – “CAD, COPD, renal failure, liver failure, splenic infarct, spinal cord infarct, paraplegia, CVA”

chief resident – “shit”
staff surgeon – “shiiiit”

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Just another day in the neighbourhood

As I was crawling into bed last night, eagerly anticipating the next few hours of sweet sweet sleep, my pager goes off.

Figuring it was just another broken arm or sprained ankle, I dragged myself to the ED only to discover, to my selfish glee, that a man had fallen into a grain auger and had partially amputated his left foot.

As doctors there is an inherent struggle in balancing the boredom of stable/healthy patients and the excitement of weird, wacky and usually unstable patients. I always feel a little guilty when my heart skips with happiness when half-dead patients roll in through the door, because in most instances, it’s something totally disgusting, gory and uncommon.

So anyway, this guy comes in, we unwrap the dressing around his stump, exposing arteries which proceed to pump half a litre of blood onto the curtains. We managed to pick out a few corn kernels and wild oats from his wound, but his ‘foot’ was pretty much a mash of dead muscle, bone fragments, cartilage and… grain. So we brought him to the OR, sawed off all the dead bits and that was that.

I forgot to steal a copy of the actual x-rays but this is a pretty good reenactment.

and this was after.

All in all, a great night.

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