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OR Jokes
during time-out, after we have announced the patient, and procedure, and the allergies, I have started saying: “All in favor say aye,” and last week during a c-section the patient said “aye” as well.
During a hysterectomy, after we take the uterine arteries down and the uterus begins to turn dusky, my attending says: “the uterus is dead.”
“Long live the uterus,” I reply.
During closing, the scrub tech always announces that the count is correct. “The count being correct is one of my top 5 favorite parts of surgery,” I say.
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New theory: there are only two people
Dumb Babies: aka the Hero. Thinks they are doing the Right Thing. Reacts to things that happen To Them. Fight for the status quo. Villains: understands their flaws & embraces them. Attempt to change the world around them. Take actions. the ubiquitious Everyman Protagonist is of course the Dumb Baby (every monosyllable Ted/Nick/Ross/Leonard/Jake sitcom hero; but also includes Ash, Aang, Steven, Thor.....pick a male protagonist) the villan is, of course, myself
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when i’m not in the throes of depression, most of the time i just tell inside jokes to myself when a specimen comes back benign on the frozen path & instead of saying “Benign!” I just started saying BINGO and pulling ports out no one understood this or actually listened when I said it for 6 weeks
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After thinking (since I've, as previously expounded to all of you at great length plus/minus interest, I've had far too much time in my head with less chance to say anything) I realized that I missed writing. That's all. I missed writing things. I can drop elaborate sentences as some symptom of an overcrowded mind, but that's what it boils down to. I do my best thinking when I have to articulate ideas in words & explain why I have those ideas. (I also think most people would do the same, if pressed, if writing were a fluid action either typing or with pen.) So I bought a bluetooth keyboard. For all the times I want to write without carrying around a laptop. I also bought an SD card dongle to make me use my actual camera more. Exercise in Upgrading My Phone While Keeping iPhone 6. Stay tuned to see if it works.
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dopamine hacking
here at the end of onc, at the end of working 15 hour days, at the end of being on call 24 hours in a row every third day and every other weekend, here now that it is all over, I am having trouble adjusting. I have spent more time outside in the past three days than the past two months combined. I stare in wonder at the trees. The crook of the branches, the way they fork at acute angles, the subtle curves in the wood. The shapes of leaves. My neighborhood is full of visual stimuli (according to wikipedia, it "contains the highest concentration of residential homes with stained glass windows in the U.S.”), of old victorian houses. I feel like I’m going on endless slow runs through hot, humid, sweltering air where you don’t sweat from any one place so much as the humidity seeps onto your skin. I am discovering pedestrian-only avenues, looking at details of stonework, the lines where the facade gives way to brick (the neighborhood is also notable, according to wikipedia, for being mostly brick houses). Admiring my neighbors’ flowers. Avoiding people (circling the block to avoid passing other pedestrians on these streets). Wearing my stupid five-finger toe shoes which I unfortunately have come to love passionately (they are so ugly and I love them so). I can’t stop thinking about the stonework on corners of buildings, or the pattern of trees planted in the park, the way water runs out of fountains here.
what I can’t do is think about work. Today at clinic I looked up when to remove a cerclage even though I’ve done it half a dozen times. I forgot how thyroid hormones worked. I forgot how to read umbilical artery dopplers. These are maybe bad examples because they are so specific, but suffice it to say that I cannot remember basic things I know well. It took me an inordinately long time to come up with an answer when someone asked me how my weekend was. I missed my exit yesterday driving to work and had to drive 20 minutes out of my way to turn around. My partner calls this parasympathetic shock, the thing that happens when an acute stressor is over. How do I differentiate this from depression? is it the same thing?
My problem with my depression—which runs in my family, which happens to my grandmother, my dad, my brother—is that I cannot differentiate it from the normal circumstances of my life. Wanting to hide under your bed all day is just how life is in med school. Feeling like you have to be 110% at work and at home you are so tired you can’t even take out the trash is also just a condition of being a med student. Only when I stopped sleeping did I bother to seek help, for something that was probably lurking for far longer. If I didn’t do this job, would I be depressed? If I didn’t bounce back and forth between being on call (and thus at work) 100% of the time (and I mean literally 100% of the time, as in awoken-from-sleep-to-come-in 100% of the time), would I be depressed? would I be able to self regulate?
The problem with medicine is that you can never differentiate these things. It demands all of your time, all of your energy, everything you care to give it and more. You can always work more. And if you’re feeling dissatisfied with your life, with your spouse, with your home—why, just work more. I watch my coworkers do it. You’re rewarded for working; you’re not rewarded for cleaning your house, or taking care of your kids, or being a good spouse, or exercising, or reading books. My inside-joke name for my OR playlist was “dopamine hacking”; I stand by the idea that nothing hacks your reward centers like doing surgery. When your acute sense of danger is someone bleeding to death in front of you, of course you’re less able to respond to less important social cues.
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sometimes things get stuck in your head that are just a too-obvious reflection of your subconscious state
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Nature/nuture: surgeons who seem tired, disaffected, unhappy until you see them in the operating room. That light switch of charisma, confidence, competence occurring over the entrails of a sleeping patient. I can't throw stones. I notice my own mood, these days, only seems normal, bright, cheerful when I'm scrubbed in. High stakes decision making constantly jacks your dopaminergic reward centers, and doing it for years just makes the change more pronounced
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Fire & Hemlock
I got called by a chemo patient having diarrhea at midnight & couldn't go back to sleep, so I started reading a Diana Wynne Jones book called Fire & Hemlock. I'm used to Diana Wynne Jones books being very comforting, but this whole book is designed to be discomforting—a young female protagonist making friends with an older strange man, terrible parents called by their first names and not "Mom" or "Dad", memories that she can't remember if they actually occurred or were dreams or fantasies, fantasies that overlap with real life, long lapses and then compressions in time. They keep making quips, puns, jokes, maybe spells about the difference between Nowhere and Now Here. In short this is not the thing to read at 3am to put me back to a good sleep.
Being able to trust an author is important to me, as any Robert Jordan or George RR Martin fan can tell you—trust that their sense of story aligns with yours, that their values align with yours, trust that this person you're giving up hours of your life to won't make you care about a character just to watch them get raped, or murdered, that nothing about the book will leave a bad taste in your mouth. Writing I think is less forgiving of cognitive biases than other art forms. Bill Cosby can hide being a pedophile for years but if your job is producing thousands of words of your thought process about how stories about the world should go, I think the flaws come out sooner. Think about the numerous authors who love killing off young girls for a plot point to motivate the Male Hero, or raping their female heroines to make them Strong. You know what these authors think, you know what they believe motivates heroism. But reader, do you believe that as well?
I trust Diana Wynne Jones, discomforted as I am. More to follow.
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In the car on the drive home the sun is warm on my arms. My feet are sweaty in socks and I drive without shoes on. I am living in three worlds at once; my home with the pale green walls, the cat, the trickling water fountain in the kitchen...the second world of work that makes me feel like everything is life or death, that makes the every day seems so long and so full, so busy and so fraught with decisions about other people's lives, my own life a thin bridge spanning responsibility for the people around me. At work every decision I make affects someone else. In the third life, I am living with my husband, in the downtown with the glass and the steel, walking in the shadows of the skyscrapers on the cool streets in the morning, catching pokemon on our phones, walking with our buddies, sleeping together under the skylights. In my head I keep flipping back-and-forth between books I've read, of good ones, bad ones, books I need to read. I keep thinking about all the research I haven't been doing, all the textbooks I don't know the contents of, the patients I will hurt because I don't know the contents of these textbooks. The gray fog of anhedonia has covered me again, stifling a day that should've been beautiful. It feels like reaching through a fog to feel good, bad, happiness, nostalgia. Some veil of indifference covering the days...going back to work will fix this. Going back to work always fixes this, because work is so vibrant and so important and everything I do there is so crucial and so highly praised or so highly criticized that my normal life pales in comparison. Everything is saturated, 100% color, the deep blue of the operating room drapes, the dark bloodstains, the white hallways, even the oversaturated computer monitors. In normal life, nothing I do matters very much. Sunsets, sunrises, evenings off come in muted pastels, light pink and blue and lavender and mint. I can sit on my couch for two hours, max, before I feel alone and meaningless. I don't know what to do with my normal life, I don't know what I want to do with my normal life. And the other life, the day dream life in my head with my husband in the downtown apartment, I have lots of time off. I read books, play games, watch films, and, probably, do other things… But I don't know what the other things are. I can't imagine that now. I went into medicine because I love the high-stakes. Because I want to be the one making difficult decisions, to be there for people when it counts, to be the one that knows what to do in any given shitty situation. Is that power, is that lust for power? I like having the difficult conversations. Parts of medicine are people saying "that must be so hard I don't know how you do it "… That's the part I want the most. I don't know what that says about me. As my grandmother used to say about me, before her dementia got too bad, I'm a winter. I don't look good in pastels.
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rolling plains of the american midwest
When I teach my med students about how to round, about how to look at labs and vitals signs, I always ask them "what does this mean?" Meaning: Why is any given numeric value important? Why is any test we get important? Why do we look at these labs, how do they guide us, and—what good do they do? As I drive through endless fields of corn looking at waving American flags in the breeze, staring at miles and miles of interstate, I can't help but think—why is this important? What does any of this mean? What good does it do?
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get laser eyes not smaller thighs
I saw a thing once about someone who asked adults & then children "what would you change about your body?" The answers of course being what you would expect: lose your belly fat versus get dragon wings, laser eyes, etc. Because to adults, social acceptance/social power is the goal of body modification. We don't even dream about the impossible anymore.
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it is treated so differently than other diseased because cancer is, usually, and is acknowledged to be (either explicitly or tacitly, by both the medical profession and the public), the thing which will end oyour life. Sure, some kinds of cancers are curable. Sure, there’s always remission. But there’s always relapse, recurrence, always some other part of your body that can be touched. A patient had become slowly more irritable over three months and we attributed it to depression or medication side effects—chemo brain is real, after all. Turns out she had a five centimeter brain metastasis in her frontal lobe which had changed her entire personality. The night before neurosurgery resected it, she told me that we had transported an entire floor of the hospital to her uncle’s house in the sixties, and was very worried about when the ambulance would come to take her back to the main hospital for surgery. The day after they resected the mass she was amazingly coherent, witty, asking us for help with her phone and describing quirks of google maps and Siri that she had found since she was admitted. The pathology of the brain met was consistent with her ovarian cancer. I watched another woman and her husband start silently crying as the oncologist told her that the new chemo we could give her would give her at most weeks, when the last round of chemo had given her neurotxicity with hallucinations that her IV lines were snakes coming out of her body, that there were monsters standing above her bed in the night. None of the chemo had worked for her, not from her first cycles to these desperate third-line attempts. Throughout it all the specter grew, lurking, spreading, no site safe, nothing in the body sacred. The cancer.
The snake that eats its own tail. the disease that kills its own host and therefore itself. It is no living thing, nothing to fight against the way you can fight a sentient enemy; you are fighting chaos, fighting the disordered entropy of your own DNA breaking down and being read wrong, of your body losing integrity, of your genes and your proteins and your tissues losing the blueprints that makes You You, losing whatever it is that keeps your Self intact.
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I had to stop reading Borges tonight, alone in my house, sitting in bed reading in my bathrobe, because the sense of unreality is much more unnerving than whatever serial killer horror movie monster we previously thought was scary. The Borges fear is that you are just mistaken about reality--told to you confidently by a narrator citing sources and explaining to you, why, exactly, you were wrong about history and geography and numbers and what the next room looks like. In “A Theologian In Death”, Melancthon “did not know that he was dead and that the place to which he had been sent was not heaven.” It continues:
One evening at dusk, he felt a chill. That led him to walk through the house, and he realized that the other rooms were no longer those of the dwelling in which he had lived on earth. One room was filled with unknown instruments, another had shrunk so much that he could not enter it; another one had not itself changed, but its windows and doors opened onto great sand dunes. There was a room at the rear of the house in which there were three tables, at which sat men like himself, who cast charity into exile, and he said that he conversed with them, and was confirmed by them day by day, and told that no other theologian was as wise as he. He was smitten by that adoration, but since some of the persons had no face, and others were like dead men, he soon came to abominate and mistrust them.
How many things about this give me physical chills? Let’s break it down:
a) not realizing that you are dead
b) not realizing that you are dead and also in Hell
c) living in your house working like normal, with some slowly growing sense that something is wrong
d) when you leave your work room you are confronted by a horrible alteration of your reality
e) alterations of physical space, a room “shrunk so much that he could not enter it”, which preys into all the reasons I was scared of Alice in Wonderland (the animated movie) as a child
f) fucking PERSONS WITH NO FACE
g) i need to stop reading this help i’m afraid to leave my bedroom now
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Paradise was less concrete: It is always night, and there are fountains of stone, and the happiness of that paradise is the special happiness of farewells, of renunciation, and of those who know that they are sleeping.
Jorge Luis Borges, Hakim, the Masked Dyer of Merv
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