Yet another reason to become a surgeon

[DrDre311]

I read the first 4-5 posts and fell asleep.

http://forums.studentdoctor.net/showthread.php?t=515522

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[San_Juan_Sun]

I love it when medicine gets a case that could easily be diagnosed by a simple biopsy, but instead they screw around for days to weeks to months running nonspecific blood tests. It's like it never occurs to them to just stick a needle in the patient and give them an answer . . .

Maybe it's just my hospital, but good luck getting a liver biopsy. My attendings won't get it unless it's intraoperative. IR seems to want nothing to do with it. Maybe I'm only remembering the times we've had problems, but we always seem to have problems just sticking a needle in it.

On the other hand, I love seeing crazy long differential lists from the medicine men. I love the medicine guys at my place (we actually get along very well, they're good people). But I have to chuckle when the working theory for a small bowel obstruction in a patient is hypothyroidism (with known belly adhesions and a CT report that says "marked narrowing at mid-jejunum").

I'm not talking smack, because they are good at what they do. It's just funny from our perspective.

 

[DrDre311]

I love it when medicine gets a case that could easily be diagnosed by a simple biopsy, but instead they screw around for days to weeks to months running nonspecific blood tests. It's like it never occurs to them to just stick a needle in the patient and give them an answer . . .

Yeah, it makes me laugh to read about it, but I remember wanting to jump out a window and run away as a student on medicine services. The best analogy to the way I feel when I'm around medicine doctors is that scene in "Office Space" where Michael Bolton is trying to get the printer to work and says "PC load letter?! What the **** does that mean?"

 

[IcedTea]

I read the first 4-5 posts and fell asleep.

http://forums.studentdoctor.net/showthread.php?t=515522

I found it somewhat interesting actually, but surgery pretty much beats everything hands down.

 

[Danbo1957]

I love it when medicine gets a case that could easily be diagnosed by a simple biopsy, but instead they screw around for days to weeks to months running nonspecific blood tests. It's like it never occurs to them to just stick a needle in the patient and give them an answer . . .

Uh-huh. Sure. That's exactly the way it happens...

 

[DrDre311]

I have had the same experience as both a student and an intern.

Resident: The skin over the thigh is erythematous and the area is markedly tender. I'm worried about an abscess.

Me: Great, I'll stick a needle in it.

Res: Well, I think we should get a white count, ESR, and CRP. That would give us a hint if this could be an abscess. Also we should get 2 sets of blood cultures. We can get a CT scan after that to confirm its location.

Me: Or I could stick a needle in it and see if stuff comes out.

Res: <sternly> That's a very painful procedure. And it would be a shame to put the patient through it if there's no fluid collection.

Me: You want to stick him twice for blood then give him the equivalent of 100 chest xrays. It'll take three days to get that done. Or I can get you an answer in 20 seconds by sticking this needle in his leg.

Res: We really don't know it's proximity to the neurovascular structures. I think there are some of those in the thigh somewhere. We could get an MRI for a clearer view.

Me: Or I could just stick a needle in it.

Res: I think we need an ID consult, and probably Gen Surg and Ortho. They may want to drain this in the OR under general anesthesia. Let's also get GI on board, since if he's immunocompromised from an undetected malignancy it could be the cause of this infection. Let's also have social work see him, and get the dietician to assess his nutritional status since that could delay healing.

Me: Great. Maybe I can get the social worker to stick a needle in him.

In the event that an abscess is discovered this conversation would be followed by a several-hours-long debate about whether to let GS drain it or whether IR should be consulted to drain it under CT guidance--the end result being that Tired headbutts Res in the junk when asked to go find every article ever written about the relative merits of I & D vs. image-guided drainage.

 

[Winged Scapula]

I read the first 4-5 posts and fell asleep.

http://forums.studentdoctor.net/showthread.php?t=515522

Good Lord...if you made it through the first 4-5 posts, you aren't working hard enough.

I couldn't make it through the 2nd before starting to drool on myself.

 

[Chronic Student]

OTOH, if you are having trouble sleeping this is a cost-effective sleep inducing treatment.

Or I could just go get my trusty immunology textbook and I would be out right after I opened it.

Both have very few side effects when compared to pharmacologic treatments.

 

[DrDre311]

Good Lord...if you made it through the first 4-5 posts, you aren't working hard enough.

I couldn't make it through the 2nd before starting to drool on myself.

Still on vacation.

 

[Winged Scapula]

Still on vacation.

What kind of vacations are they giving you kids these days?

Seems like its been at least a week you've been off.

 

[San_Juan_Sun]

Good Lord...if you made it through the first 4-5 posts, you aren't working hard enough.

I couldn't make it through the 2nd before starting to drool on myself.

WS, I think the most scary part is that these people think exercises like that are fun.

 

[Winged Scapula]

WS, I think the most scary part is that these people think exercises like that are fun.

No, the most scary part is that I used to think it was too.

 

[smq123]

I love it when medicine gets a case that could easily be diagnosed by a simple biopsy, but instead they screw around for days to weeks to months running nonspecific blood tests.

You know what I hated about medicine?

Let's say that you have a patient that is well enough for discharge to home.

On a Medicine service:
"This is hospital day #3 for Mr. Jones, a 64 year old man who has a past medical history significant for asthma, who presented with acute shortness of breath and dyspnea. Mr. Jones was still complaining of an occasional dry cough, but denied any shortness of breath this morning. He also denied any fevers, nausea, vomiting, or chills. He was weaned off his continuous nebulizers yesterday, and is now using an albuterol MDI q4 hours. His temperature is 99, his heart rate is 76, his respirations were 18, and he is satting 97% on RA. WBC count this morning is 7.1, which is close to yesterday's value of 7.3. Hemoglobin this AM was 13.2, and Hematocrit was 40. Yesterday's repeat chest X-ray still did not reveal any pneumonia. His blood cultures have showed no growth for the past 48 hours. Social work was consulted, and found Mr. Jones a local community health clinic where he can get regular care for a minimal fee. Case management has worked with Mr. Jones to find a pharmacy where he can get his prescriptions filled using his insurance plan. So, the plan for Mr. Jones today is discharge to home."

On a Surgery service:
"Mr. Jones is post-op day #1 from a thyroidectomy. Vital signs are stable, wound is clean, dry and intact. Physical exam was normal, calcium levels were normal, all labs were normal. Send him home."

Which one would you rather listen to? No wonder medicine rounds are so freakin' long.

 

[Winged Scapula]

Fixed it for ya...

On a Surgery service:
"POD #1 s/p total thyroid. VSS, wound C/D/I, PE wnl, Ca level nl. D/C planning."

 

[Smurfette]

I have had the same experience as both a student and an intern.

Resident: The skin over the thigh is erythematous and the area is markedly tender. I'm worried about an abscess.

Me: Great, I'll stick a needle in it.

Res: Well, I think we should get a white count, ESR, and CRP. That would give us a hint if this could be an abscess. Also we should get 2 sets of blood cultures. We can get a CT scan after that to confirm its location.

Me: Or I could stick a needle in it and see if stuff comes out.

Res: <sternly> That's a very painful procedure. And it would be a shame to put the patient through it if there's no fluid collection.

Me: You want to stick him twice for blood then give him the equivalent of 100 chest xrays. It'll take three days to get that done. Or I can get you an answer in 20 seconds by sticking this needle in his leg.

Res: We really don't know it's proximity to the neurovascular structures. I think there are some of those in the thigh somewhere. We could get an MRI for a clearer view.

Me: Or I could just stick a needle in it.

Res: I think we need an ID consult, and probably Gen Surg and Ortho. They may want to drain this in the OR under general anesthesia. Let's also get GI on board, since if he's immunocompromised from an undetected malignancy it could be the cause of this infection. Let's also have social work see him, and get the dietician to assess his nutritional status since that could delay healing.

Me: Great. Maybe I can get the social worker to stick a needle in him.

Well, then you also get the opposite consults (like about 4 of these last month):

paged to ER.

me: surgery answering a page
ER: hey, we have someone down here we want you to see
me: ok...
ER: 34 yo female with 2 week h/o arm pain (or leg pain, take your pick)
me: umm, I don't cover ortho.
ER: no, I know. We think there's an abscess or something, want you to drain it.
me: ok...why are you guys not comfortable draining it? (I always ask, though it's futile to think they would do it anyhow)
ER: well, we're not sure if there's an abscess
me: what's the white count?
ER: normal, but the arm seems like it might be swollen.
me: the whole arm?
ER: um, yes, well, most of it
me: and you think the whole arm has an abscess?
ER: well, we don't know where in the arm the abscess would be.
me: is there any erythema or induration?
ER: no
me: How am I supposed to know where to go? you want me to just fillet open the arm hoping that I find pus somewhere?
ER: well, we wanted you to come see what you think. It's sort of weird looking.
me: ???!!! does she have a dvt?
ER: ultrasound was negative.
me: I'm not cutting into anything unless I know where to go...did you get a CT?
ER: if you want one, we can order it.
me: why don't you do that first, and call me if there's a fluid collection.

Oh yeah, my other favorite is the perirectal abscess consult on the neutropenic chemo patient. Neutropenic + fever = call surgery to rule out perirectal abscess. But, half the time they don't even want you to do a rectal exam b/c it can cause a transient bacteremia...as if doing an I&D (if there even IS an abscess) is less likely to cause a transient bacteremia than a rectal exam!??!

 

[smq123]

On a Surgery service:
"POD #1 s/p total thyroid. VSS, wound C/D/I, PE wnl, Ca level nl. D/C planning."

Fixed it for ya...

Thanks.

I wrote really short, abbreviated notes on surgery, like I was supposed to.

Then I went to medicine, where the intern told me to "be sure and account for each medication in the A&P, each day." All 14 of them - "continue albuterol nebulizers for dyspnea, continue metformin for DM II, continue plavix for prophylactic anticoagulation, etc."

I felt bad, but (without really meaning to), I just gawked at him and said, "Why on earth would I want to do that?"

 

[Strength&Speed]

I love it when medicine gets a case that could easily be diagnosed by a simple biopsy, but instead they screw around for days to weeks to months running nonspecific blood tests. It's like it never occurs to them to just stick a needle in the patient and give them an answer . . .

I used to love considering all these exotic differentials, until I realized it didnt change management 95% of the time. Or if it did, it really didnt' matter anyway. In this case, you could have gotten a biopsy, or more smartly, do what the patient did, and do nothing. She recovered with no treatment.

 

[Strength&Speed]

On the other hand, I love seeing crazy long differential lists from the medicine men. I love the medicine guys at my place (we actually get along very well, they're good people). But I have to chuckle when the working theory for a small bowel obstruction in a patient is hypothyroidism (with known belly adhesions and a CT report that says "marked narrowing at mid-jejunum").
.

I am a medicine person, and Im sorry, this enrages me. Not you...the farking medicine people. They should not be wasting their time, or everyone elses time considering something so ******ed. It gives the IM profession a bad name. I want Osler to come kick them in the balls.

 

[Strength&Speed]

Alternatively, I "fall" on the patient with an uncapped needle, inadvertently aspirating as I attempt to stand up.

You know, like when you try to explain to your girlfriend how you got that other chick pregnant . . .

Alternatively, to be fair....I did receive a surgery consult from the team...." his creatinine is rising (now in 2's or 3's) and we have been giving him tons of lasix and he still has no UOP". Ok...so we go down there...and this guy is dry as a frickin bone. No shyt the guy isn't peeing, what do you expect. Give fluids, creatinine comes down. Surgery is kinda psycho about their post-op UOP sometimes.

 

[DrDre311]

What kind of vacations are they giving you kids these days?

Seems like its been at least a week you've been off.

Due to a scheduling F-up on my part early last year I had to take this one in a 2 week block. I'm actually a little anxious to get back to work, because I never know what to do with myself if given a lot of time off. I'm sure I'll be singing a different tune when I actually have to get up in the morning.

 

[Winged Scapula]

Alternatively, to be fair....I did receive a surgery consult from the team...." his creatinine is rising (now in 2's or 3's) and we have been giving him tons of lasix and he still has no UOP". Ok...so we go down there...and this guy is dry as a frickin bone. No shyt the guy isn't peeing, what do you expect. Give fluids, creatinine comes down. Surgery is kinda psycho about their post-op UOP sometimes.

Sounds pretty boneheaded. Are you sure that wasn't Ortho? Its hard to imagine general surgeons making that mistake since we spend so much time on peri-operative management. Of course, maybe that's just GS at your program who doesn't understand how to manage these things.

 

[DrDawg]

Thanks.

I wrote really short, abbreviated notes on surgery, like I was supposed to.

Then I went to medicine, where the intern told me to "be sure and account for each medication in the A&P, each day." All 14 of them - "continue albuterol nebulizers for dyspnea, continue metformin for DM II, continue plavix for prophylactic anticoagulation, etc."

I felt bad, but (without really meaning to), I just gawked at him and said, "Why on earth would I want to do that?"

Because they can bill for each of the problems your treating every day.

 

[Castro Viejo]

If the ABIM had an oral examination for the certification process, I'd bet it would take several days to finish.

 

[Plastikos]

I dont know. Little weird to "rule out" something in the previous sentence, then mention it, just to ultimately rule it out again in the next sentence just to show u can think (2nd poster). I always wondered why they spent time mentioning things that were obviously wrong (they even think so) and just happened to fall under that organ system, i would just feel ridiculous.

 

[DrDre311]

No no, that had to be Gen Surg. We don't know how to write for Lasix.

I actually witnessed the following conversation:

Nurse: Dr. Bone, Mr. Smith's blood sugar is 215 this morning.

Ortho resident: What? Who's that?

Nurse: You operated on him yesterday.

Ortho resident: Oh, right, sure. What were you saying, you called him sugar?

Nurse: No, I said his blood sugar is 215 this morning. Can you write him for sliding scale insulin?

Ortho resident (with a perfectly straight face, looking the nurse in the eye): What's insulin?

 

[jubb]

I actually witnessed the following conversation:

Nurse: Dr. Bone, Mr. Smith's blood sugar is 215 this morning.

Ortho resident: What? Who's that?

Nurse: You operated on him yesterday.

Ortho resident: Oh, right, sure. What were you saying, you called him sugar?

Nurse: No, I said his blood sugar is 215 this morning. Can you write him for sliding scale insulin?

Ortho resident (with a perfectly straight face, looking the nurse in the eye): What's insulin?

Ummmm... People outside of medicine know what insulin is. Was this guy/gal a foreigner who didn't understand english? Was he a space alien inhabiting this residents body.

Probably the best thing you could have done was page the transplant attending and let him know that you'd just found a set of organs for him/her in a brain dead resident.

How did the nurse respond? Maybe this resident was smarter than we give him credit. Maybe this residents 265 board score also made him/her smart enough realize that if he acted absolutely incompetent with the nurses they would never page him/her again.

 

[DrDre311]

Maybe this residents 265 board score also made him/her smart enough realize that if he acted absolutely incompetent with the nurses they would never page him/her again.

You're getting there. I wish I could get away with this kind of stuff.

 

[Winged Scapula]

No no, that had to be Gen Surg. We don't know how to write for Lasix.

I thought that since it (Lasix) sorta sounded like the word sex that you would be familiar with it.

 

[Winged Scapula]

You're getting there. I wish I could get away with this kind of stuff.

Agreed...I think it a MUCH more likely explanation that he was playing dead than actually was brain dead.

 

[DrDre311]

Agreed...I think it a MUCH more likely explanation that he was playing dead than actually was brain dead.

The nurse in question was a notorious pain in the butt and the patient already had an order for SSI which she had failed to give. The ortho resident was messing with her.

 

[Shades McCool]

I actually witnessed the following conversation:

Nurse: Dr. Bone, Mr. Smith's blood sugar is 215 this morning.

Ortho resident: What? Who's that?

Nurse: You operated on him yesterday.

Ortho resident: Oh, right, sure. What were you saying, you called him sugar?

Nurse: No, I said his blood sugar is 215 this morning. Can you write him for sliding scale insulin?

Ortho resident (with a perfectly straight face, looking the nurse in the eye): What's insulin?

Medicine consult.

 

[GSresident]

Maybe this resident was smarter than we give him credit. Maybe this residents 265 board score also made him/her smart enough realize that if he acted absolutely incompetent with the nurses they would never page him/her again.

BINGO! The first time my wife asked me to do the laundry I dumped an entire box of detergent into the washer. I don't do laundry now.

 

[MacGyver]

I love it when medicine gets a case that could easily be diagnosed by a simple biopsy, but instead they screw around for days to weeks to months running nonspecific blood tests. It's like it never occurs to them to just stick a needle in the patient and give them an answer . . .

I dont know... for liver cases like the one above I usually find that biopsies arent that helpful. Its always some nonspecific "inflammatory" process that the pathologists cant pinpoint and which does nothing to elucidate proper management beyond what we already knew.

Maybe our pathologists just suck....

 

[MacGyver]

Tired headbutts Res in the junk when asked to go find every article ever written about the relative merits of I & D vs. image-guided drainage.

To be fair to the medicine folks, I do think they are better about evidence based medicine than the surgery folks are.

Thats the luxury of having extra time to think about that stuff, whereas in surgery there's always a case in the OR waiting for you.

 

[DrDre311]

To be fair to the medicine folks, I do think they are better about evidence based medicine than the surgery folks are.

Thats the luxury of having extra time to think about that stuff, whereas in surgery there's always a case in the OR waiting for you.

It's got more to do with Tired's penchant for causing acute junk trauma.

 

[Lamborghini1315]

Yeah, it makes me laugh to read about it, but I remember wanting to jump out a window and run away as a student on medicine services. The best analogy to the way I feel when I'm around medicine doctors is that scene in "Office Space" where Michael Bolton is trying to get the printer to work and says "PC load letter?! What the **** does that mean?"

wow you read my mind.

 

[roja]

Good Lord...if you made it through the first 4-5 posts, you aren't working hard enough.

I couldn't make it through the 2nd before starting to drool on myself.

I'm so glad you said that. I was thinking the same thing.

Although, I must say there is a part of me that, while confounding, there are people who love spending this much time figuring it out. I was rounding once, they talked for an HOUR about ordering a test. Pros/cons etc. then didn't order it. *boggles* i mean, if you are going to talk about a test that long, just order the damn test.