Wednesday, March 30, 2005

if it were easy....

i haven't written in a few days, and it hasn't been because i didn't have anything to write. i guess i've been trying to figure out what topic i'd like to blather on about, without having to resort to writing about the same ol' shit that everyone else is on. thus, there will be no long rant on terri schiavo.

so instead i want to talk about mental health, substance abuse and physicians. i go to a psychiatrist and at our appointment the other day, she gave me a copy of the action report for the california medical board. this was because last time i'd seen her, i'd mentioned i was interested in maybe applying for a student position with the CMA. the one i wanted to do the most had to do with physicians that are addicted to drugs or those with mental illness. i didn't end up applying cuz i ain't got no time, but i was happy that she remembered something i have an interest in.

substance abuse and mental health are a very touchy issue for me, given that i'm going into a field that is ok with these diseases in anyone but the people in the field. i have a strong family history of drug and alcohol abuse on both sides, and have been very afraid for a long time that i'll somehow find myself an addict. thus far, that fear coupled with a very low amount of alcohol dehydrogenase has kept me clean, but i still worry about it plenty. and while i'm seeing a psychiatrist for ADHD, which could reasonably be considered more of a neurological disorder, i still feel weird about admitting i go to the crazy doc and take mind altering drugs every day. i don't keep this info secret, but i do worry that one day that frankness will bite me in the ass.

seeing the action report scared the shit out of me. physicians lose their licenses for DUIs, petty theft, depression-all sorts of stuff that for anyone else would be just a little misstep in life. lots of drug addicts in there, injecting themselves and writing illegal scrips. the list was long.

so how did those poor docs find themselves losing their licenses? my carpool partner wondered how many of them were just bad people, and how many were good people that found themselves in a bad situation? i said i figured most were the latter. i say this because i can totally see how it could happen, especially in the last month or so.

it's apparent that our class isn't doing too well right now. i'm willing to bet 2/3 of us fit the clinical description of depression. i've been pretty sad myself, for a myriad of reasons, but mostly just because of all the stuff i have to do every day. i'm constantly tired, waking up early after staying up late, not studying effectively enough to satisfy my perfectionist psyche. after going to lecture and lab for 8 hours a day, i come home and try to shovel in more material, in hopes that i'll actually get higher than a 71 on this next exam.

it's not that i can't hack stressful situations- i once worked 21 hours without even noticing it and spent 3 years on call 24-7 (EEG techs aren't too plentiful, even in LA). most of the people in my class that i've talked to feel the same way. the problem is that we do all this with so little instant gratification, which our generation has gotten used to. we won't see the results of all our sacrifices for another 3 1/2 years, when we match. until then, we study our asses off to barely pass, doing all sorts of community service and club stuff in our spare time to look better on paper.

this last part is especially true for DO students. as a 4th year recently told us: "why should residency directors pick you when they can pick an MD?" she was trying to tell us that we have to go head first into what we love, and start early. but some took that as proof that we're all destined to settle into primary care, because that's what everyone expects of us. that is, unless we find some way to walk on water before match day.

so now we mope. we cry. we tense our shoulders and walk with them hunched over, staring at the ground. we're depressed, and what is to stop us from self-medicating?

nothing, really. we were told in a recent lecture on opiates that medical personnel abuse oxycontin and fentanyl like it's going out of style. the stigma attached to getting help for mental health issues when you're supposed to be a paragon of health causes a lot of us to look to a way of forgetting it all for a little while. we have counseling at school, and they tell us to get help if we feel out of control. they even say that they'll get us into treatment for addiction if we tell them we have a problem, but how many are comfortable risking their education to ask for it?

we're supposed to just suck it up, right?

it all comes back to that stupid cliche we've seen over and over on ER: we are expected to be perfect, but we can't live up to it. being at the pinnacle of society, more hardcore than the regular people is why we want to do this job in the first place, but we still hate to find ourselves the victims of our own hubris. i could get into a whole rant on that, but for now i'll just leave it.

in other news, i'm getting braces! the invisalign ones! straight teeth is something to be happy about.

Tuesday, March 15, 2005

why we need to turn down the howard stern and start talking in the OR

i was reading an interesting article on when anesthesia fails

he mentions briefly about how in certain spinal procedures the neuro monitoring requires anesthesia levels be adjusted. when i read that my heart sang, because in my former life i was a board-registered neurodiagnostic technologist, and this little-known issue was my whole life.

i worked for five years around southern california doing intraoperative monitoring during various brain and spinal cord surgeries. there was so much time spent arguing with surgeons and anesthesiologists over gas levels during surgery, which often ended up being just a masturbatory gesture because they couldn't see how their levels of inhalational gases left my signals weak or non-existent. in the end, when we failed to communicate or agree on how to proceed, the patient suffered because they weren't getting the best standard of care during a sometimes very risky procedure. i was always frustrated because the anesthesiologists just needed to shut up and do what i told them to do, and for some reason they didn't like being told that.

which is why i knew i needed to get the fuck out of my dusty corner of the OR and get over to the sterile side of the room. they'll listen to me then, those bastards.

but i digress.

somatosensory evoked potential (SSEP) , motor evoked potential (MEP) , EEG and EMG monitoring used during surgical procedures can be very useful when done properly (here's an article on intraoperative monitoring 101 for those interested). the problem is, to be maximally effective there must be complete cooperation between patient, surgeon, tech and of course, anesthesiologist. it's not just a matter of keeping inhalational anesthetics within a range that will lend itself to accurate assessment of signals. because the techniques are varied for different types of procedures, the surgeons also need to be aware of which modality will be used and what their role is in assisting the tech.

for instance, during procedures in which pedicle screws are placed, EMG can be used to verify that the screw is not in contact with any nerve roots. it's simple enough in theory: place recording electrodes on muscles that correspond to the dermatomal levels in question, then take a monopolar stimulator (or a nasopharyngeal EEG electrode for the creative), contact the screw hole or screw itself, and send a small current through. if there is a muscle response below a certain threshold, the tech can tell the surgeon that they might want to re-place that screw. the surgeon must know how to place the stimulator and be in constant communication with the tech about what level is being stimmed, and whether they have dropped the stimulator on the ground, again. pedicle screw stim also requires that there be no muscle relaxants on board. since this is often done concurrently with SSEPs, the anesthesiologist must now make sure that both inhalationals and muscle relaxants are within the range to ensure a true positive or true negative result. being anesthesiologists, they don't like that. so they yell, make snide comments, ignore my requests, or lie to me, which is kinda dumb since 1) i can read the gas levels on the machine and 2) it's not hard to tell when someone is paralyzed when you are testing their neuromuscular junction.

i understand their position- it makes their job much harder and increases the chances of the patient having some bad memories of the surgery. but it's important if the surgeon wants to make sure their patient won't have post-op nerve pain or worse from a mis-placed screw. everyone benefits from a good outcome, and everyone gets the shaft from a bad one. which is why you'd think the surgeon, who has a vested interest in their patient not waking up with pain or neurological deficits, would help us out here and maybe advocate for the tech to the gas man in the evnt of any trouble. but you'd be wayyyy wrong there. even though they often are annoyed by their drug-pushing colleagues, a little tech buzzing around them having the gall to ask for a little fucking help here is much more annoying.

circulating nurses, scrub techs and slimy instrument reps weren't much help either, preferring to ignore me unless my shit was in their way.

thus, although pedicle screw EMG is ideally a five minute test, i never had as many problems with any other modality than with this one. and on top of all the screaming going on, something technical always went wrong: a cord was too short, or not plugged in; 60Hz interference in the room completely obliterated the EMG signal, so everything was sequentially unplugged until the offender was found; the stimulating or recording electrodes didn't work; or as mentioned before, the fucking surgeon dropped the stimulator.

communication during surgery is critical. i know that seems like an obvious statement- but with the cavalier, military-style attitudes inherent in the OR, it was frowned upon for a lowly tech to direct anything, even if it was required for us to do our jobs properly.

in an effort to change this and increase communication between neurodiagnostic tech and the physicians that loathe them, a wonderful colleague of mine (a complete hardass if there ever was one) developed this: The Los Angeles Anesthesia Friendliness Scale.

LAFS was a great way to kill two birds with one stone: get the anesthesiologist to do what you need them to do, and use it to feign interest in their specialty and all its crazy sleepytime drugs. they like that because it makes them feel important and special after being yelled at by surgeons all day. when you make them feel special, they will become your best friend and then everyone is happy.

i must end this by saying that even though anesthesiologists made my life a daily hell for five long years, i can forgive them now that i'll never be stuck behind their stinking machines ever again. you can go back to your wall street journal guys, cuz i ain't mad at ya!

Thursday, March 10, 2005

insert "MTV's the real world" style intro: "this is the true story, of 200 strangers, picked to live in a lecture hall..."

our class is going crazy. a combination of long hours in lecture, a low average on the last exam and spring break not.coming.soon.enough has driven us to become lame parodies of the students seen in movies like gross anatomy. we don't yet know who is the token drug addict or gunner-student-who-has-a-nervous-breakdown.

shit-talking is an art right now- there's not even a clear pattern to who is this week's slut or asshole. our ethics classes turn into pissing matches on who can be the most paternalistic and judgemental. i really didn't expect this. i thought we were above such asinine behavior.

and yet, here i sit venting to a blog. that no one reads. so what's the point?

the point is, as a classmate said today, we'll all be hugging again when MS2 starts. at least for a couple of weeks.

Tuesday, March 08, 2005

intros and assholes

i feel like my first post needs to be all witty and make me sound super creative and literate, but it just isn't happening right now, so i might as well give a bio thingy:

- i am a first year med student at an osteopathic institution somehwere in the US. yes, yes, i know, i'll talk about it later.
- i am a girl.
- married, no kids.
- i like the brain and hello kitty.
- i also like tomatoes.

so i must start by asking a question: how much is too much information to tell a medical student? i am halfway through my second semester of med school, and i have had three people already ask me about their asses. i know a little about the booty, but not nearly as much as any doctor that actually is a doctor. why can't they ask one of them?

now i admit one was a family member, but that means two weren't. they were complete strangers, and after five minutes of knowing them, i also knew about their buttholes. the worst thing of all wasn't that they asked me about that area, it was that they didn't even buffer it with some questions about chest pain or swollen ankles. it was "hello, nice to meet you, i've got a question..."

random person #1: "i have a question, since you're gonna be a doc. i've got this thing on my ass.."
me, horrified: "um, on the butt cheek or by the anus?"
random person #1: "on the cheek. it's big and red and hurts like hell, and i have trouble sitting."
me: "sounds like it might be a boil or something. you'd better get it checked out"
random person #1: "i'm just embarrassed about going to the doctor about that kind of stuff."
me, in my head: "yet asking a med student you don't know at all is perfectly comfortable for you?!"



random person #2: "maybe you can help me- i've had some trouble...down there...with leaking"
me, wondering if i have "asshole expert" written on me somewhere: "urinary or bowel?"
person #2: "the last kind. and, it bleeds a lot."
me: "um, wow, like a lot of blood? is it dark or bright red?
random person#2: "bright red"
me: "ok, rectal bleeding is really never a good thing, especially with bowel incontinence, so why don't you get it checked out by your doctor?"
random person #2: "yeah, i should do that."


family member: "i need some medical advice"
me: "only if you promise to actually take it"
family member: "________ (her husband) has this hole in his ass."
me: "what? like an accessory hole?"
family member: "yeah. it occasionally drains and he says the stuff that comes out burns really bad"
me: "how long has he had this?"
family member: "well, since i met him, so 20 years.. it gets bigger all the time, and now he can stick his finger in it"
me: "what the fuck?! dude, he needs to ge that taken care of"
family member: "i have him soak in the bath, and it cleans it all out nicely."
me: "no, it doesn't. he has a fistula, and needs to have it sewn up. like, now."
family member: "sewn up surgically or something? oh, he's way too squeamish to have that done"

as an aside, i was surprised that fistulas aren't mentioned but casually in Robbins.