itsannienomouse

[itsannienomouse]

Art Imitates Life

It is a well-known knowledge that every art ever made, every story ever written, every television stories every screened were all based on real life, at least part of it. Perhaps a little drama was added for aesthetic, but everything man made was inspired by God’s screenplay. Perhaps, it could not be truer than it is in residency.

Every time I meet someone outside the medicine world and introduced myself as a surgeon (or a surgical resident at that time), the most common question, after where and oh wows, would be: Is it like Grey’s anatomy? I kid you not! The most popular question I have been asked since in entered my residency, and always a reference to Grey’s.

I didn’t mind it, not at all. In fact, I would proudly say, yes! Yes it is. The medicine, the shifts, the inability to have life outside the hospital, and yes, of course, the DRAMA! And the sex :D

While I had decided to enter medicine far before I was exposed to any medicine TV shows, I like those shows nonetheless. In fact, I could almost always relate. And Grey’s, I seriously say, the drama is real. And I’m sure I’m not the only surgeon who feels that way or had that life. When you are confined to a place for more than 24 hours more often than not, with the same people, the same struggle, there bound to be some difference, some love, some lust, some tears, some laughter, some drama and a lot of sex.

One instance I am remembering right now is when I was a second or third year resident. I had my 24 hours shift at one of the community hospital that was a partner with our teaching hospital. Every shift consists of two second/third year residents and every month there is an on call chief that has his rotation at that hospital. I should probably explain, the chief resident in our residency system is the senior on the last year of their residency and the most senior at every rotation.

It was a Sunday, so the shift started at 9 A.M at the ER and would end at 6 A.M the next day, where daily schedule of OR and clinics continued. I was accompanied by my batch-mate, Dylan, on that day. After we screen the E.R, did few lacs in the E.R and an appendectomy procedure in the O.R, we grabbed some lunch and went to our room/temporary lounge.

The resident lounge in that hospital was under renovation at that time, so they gave us two VIP patient’s room as a temporary lounge to rest in. Each had two bunk beds in it, TV, refrigerators, toilets and all that. The rooms were to separate male and female residents, but we almost always end up just using one room regardless the gender of our shift partners. 

So at around two P.M that evening me and Dylan went to one of the rooms (the one usually used) and found our chief of the month, Henry, lying sleeping on one of the lower bunk beds. We were not that surprised; we had an idea he was in the hospital. Our attending had a patient in E.R. and had told us that Henry was going to come and see the patient and prep her for surgery if necessary. We were just confused how we missed him in the E.R. I forgot the case exactly, but I remembered the surgery was cancelled for that day. I thought maybe Henry just didn’t want to go home.

Dylan went to the other bunk bed and climbed to it’s top, so I took the lower one. I must have dozed off; I woke up with a start to a noisy bed creaking and a snoring sound from above me. I opened my eyes and saw Henry was up. He saw me awake, came towards me and caressed my cheek.

No… it is not a story of sexual harassment!

Henry is a married man, a father of two, my senior and a friend. We had a few rotations together and at one of those rotations, we end up in bed together. I remember the first time we slept together, we were having a bad day at the hospital, so at end of the day, we decided to go out and have a few drinks. No one else wanted to join, so it was just Henry and me. In between drinks, Henry told me a sob story of how he married the wrong woman and only found out he loved someone else just few days before the wedding. But the wedding wasn’t and could not be cancelled, so he got married, but for two years he also had an affair with the woman he loved.

Honestly till date I do not know if that was a true story or just a sob one to get me into bed with him, but it worked. We got drunk and we had sex. It wasn’t something any of us regretted. Yes, we were drunk, but we were still in control of our decision. For Henry, it was probably a sport, for me, it was entertainment. I knew he had a family, so no strings attached. We started seeing (more accurately sex-ing) each other on and off since then. On that day of my shift, I hadn’t seen Henry for weeks, probably months, due to our schedule.

I smiled and sat up; he started kissing me and touching me everywhere. I giggled and pointed upwards, referring to Dylan who was fast asleep at the top bunk. Henry got up and left the room. I guessed he just decided it wasn’t worth the risk.

Few minutes later I got a text from him to meet me in the next room, the empty room we never used. I smiled, freshened up and went to get some. Sure enough we did it… twice, as quietly as possible as to not attract any nurse or anyone to that room. It was fun. Henry left form home after that and I continued my shift with Dylan.

Henry and I are still friends till date. However, the sex part isn’t a part of it anymore. Henry is a serial womanizer. A while after that day, I found out he was sleeping with a junior of mine. Although that did not break my heart, it bugged me a little, especially that their affair was not well hidden like it was with me. I was afraid if they were exposed, I would be sucked in too and I didn’t want that to happen. So I stayed away from Henry for a good long while. We had our fun once or twice more after that, but when Henry became an attending in a different hospital, our relationship turned into just friends, with no benefits. 

There are a lot of stories about Henry and his adventures, but it is his story, not mine to tell. As I said in the beginning, the stories, the drama, the sex… they are all real in the residency world.

[itsannienomouse]

Surgical Pearls #2

"While you may know that this is a terrible injury and go 'boy i hope we can fix it', it is incredibly important for the operating surgeon, the person who is the captain of the ship, to not loose composure. I think when things are really in trouble, that is the time when you can't yell, CAN'T YELL. Because most people don't perceive being yelled at as a good time and would prefer to not have it happen again. So now they are terribly anxiety ridden and much more likely to make a mistake" -dr. Thomas Scalea- From Behind The Knife Episode 117: The Boss of Shock Trauma, dr. Thomas Scalea

[itsannienomouse]

Surgical pearls

From my favourite surgical podcast Behind The Knife

"Don't ever take training in a country that forces you to limit your time in the hospital with patients to 80 hours a week" -dr. Kenneth Mattox-

Episode 17: The Mattox Maneuver and Much More with dr. Kenneth Mattox

[itsannienomouse]

You’ve Been Pimped! Again!

What exactly is pimping? If you have ever been a medical student or resident in any discipline, you probably already know. It’s ostensibly a form of Socratic teaching in which an attending physician poses a (more or less) poignant question to one or more learners. The learners are then queried (often in order of their status on the seniority “totem pole”) until someone finally gets the answer. But typically, it doesn’t stop there. Frequently, the questioning progresses to the point that only the attending knows the answer. 

So how did this time honored tradition in medical education come about? The first reference in the literature attributes it to none other than William Harvey, who first described the circulatory system in detail. He was disappointed with his students’ apparent lack of interest in learning about his area of expertise. He was quoted as saying “they know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped!”

Other famous physicians participated in this as well. Robert Koch, the founder of modern bacteriology, actually recorded a series of “pümpfrage” or “pimp questions” that he used on rounds. And in 1916, a visitor at Johns Hopkins noted that he “rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”

So it’s been around a long time. And yes, it has some problems. It promotes hierarchy, because the attending almost always starts questions at the bottom of the food chain. So the trainees come to know their standing in the eyes of the attending. And they also can appreciate where their fund of (useful?) knowledge compares to their “peers.” It demands quick thinking, and can certainly create stress. And a survey published last year showed that 50% of respondents were publicly embarrassed during their clinical rotations. What portion of this might have been due to pimping was not clear.

Does pimping work? Only a few small studies have been done. Most medical students have been involved with and embarrassed by it. But they also responded that they appreciated it as a way to learn. A 2011 study compared pimping (Socratic) methods to slide presentations in radiology education. Interestingly, 93% preferred pimping, stating that they felt their knowledge base improved more when they were actively questioned, regardless of whether they knew the answer.

So here are a few guidelines that will help make this technique a positive experience for all:

For the “pimpers”:

Make sure that the difficulty level of questions is reasonable. You are testing your learners’ knowledge, not spotlighting your own mental encyclopedia

Build the level of difficulty from questions that most can answer to one or two that no one knows, then switch to didactice teaching of the esoterica

Don’t let one learner dominate the answers; gently exclude them and solicit answers from others so they get a chance to participate

Provide positive reinforcement for correct answers, but don’t resort to negative reinforcement (insults) when they are wrong

Go Socratic when the answer is not known. Step back and review the basic concepts involved that helps your learners arrive at the correct answer.

For the “pimpees”:

Read, read, read! You are in this to learn, so study all the clinical material around you.

Talk to your seniors to find out your attending’s areas of interest. There’s a lot of stuff to learn, and this may help you focus your rounding preparation a bit. It still doesn’t absolve you from learning about all the other stuff, though.

Don’t be “that guy (or gal)” who tries to dominate and answer every question

If all else fails, and it’s one of those “percentage” questions, use my  “85/15 rule.” If the issue you are being asked about seems pretty likely, answer “85%.” If it seems unlikely, go with “15%.” It’s usually close enough to the real answer to satisfy.

Bottom line: Pimping is a time-honored tradition in medicine, but should not be considered a rite of passage. There is a real difference in attitudes and learning if carried out properly. Even attendings have a thing or two to learn about this!

Reference: The art of pimping. JAMA. 262(1):89-90, 1989.

[itsannienomouse]

DOT

One of horrific thing that could happen to you as a surgeon (and anaesthesiologist, for that matter) is a DOT, death on table. It has always been considered a taboo. Surgeons would quickly close an unstable patient with clamps and gauze inside him and rush him to the intensive care when things get catastrophic in the OR. All surgeons hope the patient gets better in ICU for a re-operation, but most often than not, the patient dies in the ICU. This, dying in ICU instead on the operating table, is viewed as socially more acceptable than the other.

All my years in residency, there had only been one incidence where the patient died on the operating table. I was in my senior year of my residency, a chief, and had an orthopedics rotation in another hospital, an extension of our institution. It was my first day there. Well, I have been in that hospital a couple of times, different rotations, but that was my first day after a few months apart. There was a total hip replacement surgery, my co chief was sterile in it with the ortho resident and attending, I was observing.

On one brief moment I went near the anesthesia machine, just near the patient’s head. The patient was under spinal anesthesia and had a nasal canule on her with oxygen flowing helping on her oxygen level. But I noticed something was not right, she wasn’t awake as usually patients under spinal anesthesia were, and her breathing wasn’t normal. I tried to wake her up, but she wasn’t responding. My loud voice got the attention of all working on her hip. The anesthesia resident and nurse was nowhere to bee seen in that OR. Right that moment, the machine beeped alarmingly, and we all saw the oxygen saturation of the patient was dropping rapidly. I screamed out for the anesthesiologist, the operation halted.

A second year aesthesia resident came in looking bewildered and trying to grasp what was going on. She poked around the monitor and the EKG leads on the patient. The anesthesia nurse on the other hand, more experienced on the field, knew better. He took the bag-mask device, placed the oro-pharenyeal airway device and closed the patient’s mouth and nose with the mask and started bagging her. He said in calmed hushed whisper to the resident to call the attending.

I once read that anesthesiologists are surgeon’s heroes. They are trained not to show panic, even in the face of catastrophic event, when the surgery is still going on. That was what the nurse did with his calm, hushed whisper.

The attending came, took over the bag-mask, asked for intubation tray, commanding still in calmed hushed voice for medication and action to take. Things went spiraling so fast, I couldn’t track their movements. We moved back from the table, allowing the resuscitation process by the anesthesia team. CPR was done over 45 minutes before the anesthesia attending gave up and invited my attending to talk to the family.

The family, of course, couldn’t comprehend what a surgery on the leg resulted on the heart to stop. There was shouting, threats of sue and cries. Both the attending took it calmly and answered all their questions, guided them through the process and explain and re explained again the sequence of that catastrophic event. I guess in our line of field we are bound to catch some bad luck like this and should always be ready to handle it.

[itsannienomouse]

Early Morning Rage

When you were just an intern, your discussion laced with rage with other division is an instruction from your chief. So you marched up to that specific person, with limited knowledge why you are upset, and lay out everything your chief explained to you, with equal or more rage if course. And when that person retaliate, you are not sure how to answer so you get angrier.

It is different when you occupy the chief position. Early morning when the anesthesiologist cancels your op patient, who had been cancelled before, due to high blood pressure (same reason), you (i.e me) who hasn’t been sleeping well fills up with rage.

First you call up the internist that was spose to monitor the patient’s blood pressure since his last cancellation, and she said she had given the medication. So you marched up to the nurse to find out where the problem is, and they told you the IV cath kept getting blocked. You asked them if they tried contacting the oncall resident, they did, but no one came.

You (i.e. me) roared up and all hell broke lose. Then the nurse told you calmly that the med had gone in since morning and now the BP is alright. You calmed down and called the anesthesia resident and told him the good news and he repay you by saying that it was too sudden of too much drop in BP… they might have to cancel the op anyways...

……. ….. … .. .

U just lost it

[itsannienomouse]

Late Night Thoughts

I’m sure you are probably curious about the affair story, but i’m gonna keep it aside for now. At this present time, i’m in my last year of residency and the chief in my program. Looking back and trying to type in words the experience of the whole 5 years seems overwhelming. Where do i start, what should i focus on? 

I have just started reading When Breath Becomes Air by Paul Kalanithi and how i wished i had his talent in writing. Everyone has their own stories to share and so have i. My story is probably mediocre, borderline boring, but it is my story and i want it out there. 

I haven’t written in a long while, i realized, but bear with me, i will be continuing my blog soon enough ;)

[itsannienomouse]

The Affair

Every good story has an affair story, and surgical residency has few of the best ones. When you are confined to one place almost 24 hours a day, 7 days a week, there is bound to be some sexual tension and of course… an affair.

Mine started the first week of my residency life. We were called by our seniors (i.e. residents that had started 6 months earlier) for briefing and a little warning. That was when I saw him the first time. He was not the tall dark and handsome kind with an athletic body. He was a little plump, just enough height and little dark. I guess my choice of guys from their physical appearance didn’t change much since I was a teenager. I like them a little plump and just enough height.

I had always fallen for guys who are playful, flirtatious and almost always a player. Now, at that first day I saw him, I did not know that about him, but I just had this feeling, a crush at first sight. He was there in front of the auditorium, telling us the house rules in stern voice and I just had to have him notice me. I whispered to my classmate next to me, the only other girl in my batch, Gissele;

“I think I have a crush on him”

She looked at him and then at me like I’m crazy.

“Him?” her face contorted like she felt pain she never felt before and trying to decide if she liked it better than normal pain she felt.

“You probably like him because his name is the same with your professor.” She said when her face had normalized. It was true, his name was Alan and it was the same name as my professor who I worshiped and idolized. Professor Alan is a trauma surgeon; it was because of him that I have this dream to be one hell of a trauma surgeon. He was and still is my inspiration.

So Gissele was trying to rationalize my crush on this Alan, and maybe there was some truth in it, who knows. All I knew and felt was that I was attractive to this so-so looking guy and I can’t explain why. At that moment, it was just this happy feeling that I have a crush and a crush has never failed to make me wanna wake up every morning and go to school or work. It didn’t matter if he liked me back or not.

Little did I know at that same moment he had similar feelings about me as I did about him.

A few days after the briefing, we had this patient and hospital safety workshop in preparation for hospital accreditation, and guess what?! I was in the same workshop group with Alan. Boy how excited and happy I was. I couldn’t look at him without my face getting flushed. He was being cool and rather distant, which made me like him even more. Gissele was in the next group next to us, she looked at me, smiled sheepishly and raised her eyebrow and nodded towards Alan. I giggled and felt my face getting warmer… I knew I was blushing.

The whole workshop ended without any interesting event between Alan and me. The only interaction I had with him the whole time was when we had the post-test quiz and I had the cheat sheet, since I was also involved in the organizing. I was sharing the cheat sheet around to everyone in my group and he asked me for it. Simple conversation, nothing special, no interesting small talks, no flirts, but yet my heart raced and I felt giddy.

Right the next day after that, still at the same workshop, at lunch break, I was sitting on one of the sofa playing with my phone, or reading something, I can’t clearly remember. Anyhow, he, Alan, sat sliding next to me and started playing his iPad, oblivious to me sitting there. My muscles stiffened. My heart raced. And I’m pretty sure my face was changing color slightly. Whatever I was doing, be it my phone or a novel, I couldn’t concentrate anymore. I could hear my heart beat in my ear. I was reading each line twice…. That’s it! I remember, I was reading.

I got a little nervous and uncomfortable sitting there with stiffened muscles, pretending like I’m enjoying my novel in silence. So I decided to move. And just as I was about to stand up, he acknowledged me.

“So I heard you made the best sangrias in town” he said without looking up form his iPad.

I remembered just having a conversation with one of his classmates the other day when we had our night shift together. We were discussing about alcoholic drinks and then talking about sangria. I casually mentioned I could make sangrias and sometimes I like it better than the ones you get from the bar. I didn’t know male surgical residents like to gossip…. Or share everything with each other… but apparently they do!

I laughed nervously, “I did not exactly say that” I said. “I can make sangrias, but they are far from the best one in town”

“Hmmm” he nodded, still not looking away from his iPad.

There was another silent. Again I started to get up and once again he spoke, “So when are you going to take me to taste the best sangria in town?”

I laughed; he was definitely flirting with me.

“Sure,” I said. “Anytime you want.”

[itsannienomouse]

Aquariums

Being in a surgical residency is like being in aquarium; you are stuck in one glass box where everywhere you turn you meet the same people while everyone else outside the box watches us like their favorite TV drama -Annie Nomouse-

[itsannienomouse]

The Beginning

Although I have said before that this memoir is not in chronological order, perhaps it would be more interesting if I start with the day I was accepted into the surgical residency. See I actually wanted to do my residency in town B, but pressure from my dad, I took my entrance exam in town A, where it is supposedly the best education system for medicine and surgery. I never expected to pass the exam, leave alone be accepted into the program. But as universe had it, I passed the exam and was called in for an interview. Now here is where all the madness began.

As I entered the interview room, I recognized almost immediately everyone that was present there. My interviewers. The first one is the new dean of the surgical residency, a pediatric surgeon, dr. Kathrina. The second one is a well-known, most beloved female surgeon, Professor Madisson, a senior plastic surgeon; in fact I was told she is the first female surgeon in our country. The third, was a psychiatrist specializing in children psychology, dr. Lau. As nervous as I was, I tried to smile.

One thing you should know, I wasn’t dressed well enough. That morning when I chose my costume, I thought it was appropriate. But as I look back, I realize it wasn’t. I was in that phase of life where I was all hippie, long skirts, off shoulder tops, necklace and bangles and all that sorts. Of course I couldn’t dress that way for a formal interview. And I thought I should wear pants and not skirts to show that I have my male side and that I belong to surgery. (as you all know after watching many of medical series, surgery has been considered as a male game). Problem was, I did not possess a decent pair of pants. All I had were jeans and a baggy army colored pants. Suffice to say I went with the army pants (jeans were considered informal). It was hanging lose on my hips with pockets all over its font and sides. I had a checkered brown shirt that was body fitting on top of it and a black canvas shoes. I had my long hair tied in a pony tail, my brownish red hair. Writing this down now I’m realizing how funny and miss matched I looked back then. I wish I had a picture I could remember it by. A colleague of mine told me years later when we had become more than family that that day he thought I was a mess, ignorant, a rocker chick and definitely did not deserve the limited space for surgical resident in that prestigious campus.

Well anyways, I was in there, feeling all eyes on me judging. Questions after questions about why did I chose this major, which surgical figure did I idealize and why, what made general surgery so appealing to me and last but not least the question that every female surgeon wanna be was asked, how will you handle your family, husband and kids between crazy hours of surgery. My answers to those questions at that time did not matter. I answered them as I was prepared by my friends and seniors before me, a logical, enthusiastic yet humbling answers. In reality, all honestly, I chose surgery because I fell in love with it ever since my first night shift in the ER in my med school.

I remember that day quite clearly, I helped an ortho resident repair stump of a traumatic amputated finger and later on that night I was given the chance to do some sutures on a laceration. And when morning came, my decision was firm, I wanted to be a surgeon. As simple as that.

And family? Well, I never thought of having kids, not even now when I’m almost in my third decade, but didn’t seemed like the right answer that moment. I did not want them to think I’m a sociopath (which I fear what my psycho test showed) and worse, them asking me many more questions about it.  

Anyways, in the middle of the interview the door opened and the Head of the Surgical Department walked in, an ambitious cardio thoracic female surgeon, dr. Alisson. There was an air about her, I could not (and still haven’t) make up my mind if I liked her or not. I knew at that time, even before my interview that she was a dear friend to my boss whom I was working for before the entrance exam. She sat down and looked at me with piercing eyes. Curious and somewhat devilish. I was not comfortable with it but I tried hard not to show it. She asked me if I knew what it meant to be a surgeon, if I knew the sacrifices I would have to make. Then she said something about physical fitness and moving quickly. And then she told me to stand up.

I stood up. Corrected my pants that were hanging loose on my hips. My shirt was half tucked out. (Oh My God!!!). She then told me to ‘walk Fast’ to the end of the room. I did. In mid way she commented “Is that your quickest move?”

I said “You said WALK fast. This is walking fast”

“Turn around and run”

I turned and ran towards her. She threw something at me and told me to catch. I reached out while running and almost had it but it slipped and I kicked it to the corner of the room.

My heart was racing. I saw the thing she threw at me. It was her cell phone.

“I’m so sorry” I muttered. She smiled, again a devilish grin.

“You are a mess….” She said. I felt my face burning. “Such like a surgeon”

I knew it then, right that moment, she had made her decision and that I was in for sure!

PS: For the longest time, I thought that whole thing she did to me was a special thing and that she took interest in me. Whether it be because she was a friend to my boss or it was because she saw something in me, I had always thought I was the only one she did that too. Few years into the program I learned she did similar stunt to few other female residents upon interview.      

[itsannienomouse]

Introduction

July 28th 2015

 Not enough sleep, not enough coffee and overly agitated; I skipped on rounds and sat in the Canteen for some coffee and soup. The only thought running through my mind is that I want to travel so badly. And then followed with I need a drink… an escape basically. And then I remembered, how easy enough it is to escape into another dimension while reading a novel. Better yet, while writing it. So I took out my lap top and started this.

I had always wanted to write this memoir, just was never motivated enough. And today seems like a perfect day to start.

Disclaimer though, what I’m about to write were all true incidences in my surgical life. Names are changed and the chronology is not in order, but these are the moments that are most memorable.