Tuesday, August 23, 2011

Scrubbing


Third year can be exhausting. When I was on my obstetrics and gynecology rotation, my car rolled into the hospital’s dim parking structure anywhere from 4:45 to 5:30 in the morning and I rolled out sometime between 5:00 and 8:00 at night. The time stretched between those two poles was like a slingshot propelling me from room to room, task to task—a frenetic scramble to stay on top of what my team was doing. But perpetual motion is good. Because pause gives sleep an idle target upon which to pounce. I remember one day in particular, when my knees buckled halfway through a 4-hour laparoscopic cystectomy. I could barely believe it myself, but after staring at a screen in the dark for 2 hours, sleep was upon me before I could sidestep its claws. I ended up catching myself with a startled yelp before I did something really embarrassing like wake up on the OR floor. My resident asked if I was alright, probably assuming I had tripped, because honestly that’s what it looked like. I quickly chimed “yeah, I’m okay.” The surgery went on. I was wide awake for the remainder.

Being in the operating room, or OR, can be tricky. Of course, staying awake during surgery is an obvious tip every student should keep high on their list of priorities. But there are a number of more delicate rules, most of which become habit over time. And this is precisely the problem. For surgeons who have scrubbed into thousands of surgeries, OR etiquette simply becomes nature. This means that trying to explain to fresh 3rd year students how to scrub into a surgery is like trying to explain to an alien how to order drinks and have fun at a bar. Even if you could verbalize all the proper steps, your alien is bound to forget something. And the results are always awkward and frustrating. So I decided to piece together some advice for anyone having to scrub into surgery for the first time. I present to you my very own medical triad:
  1. First—and most important—is come to peace with the fact that you will look like a complete buffoon the first half dozen times you scrub in. In every operating room, there is a field of items, including the patient, which are draped in blue. This is the “sterile field” in which the surgeons and scrub techs work. You will violate this sterile field multiple times in your first few surgeries, and people will scream things like “NO! Don’t do that!” but it will be too late. You will have touched the untouchable. Sterile will rendezvous with non-sterile. And the result will be great shame and condemnation. But 99.99% of the time, the patient will not die. So unless you are in the unlucky 0.01%, the best advice I can give is to be fully resigned to the fact that for your first few times scrubbing into the OR, you enter as an alien buffoon. So be okay with laughing at yourself. It’s a healthy defense mechanism.
  2. The only other real key advice is to make sure to wear your facemask ANYTIME you enter the OR.  Even if you are not scrubbed in—even if you are just peaking in for a millisecond to say “bye” to your gorgeous resident—put a facemask over your mouth. Your kisser is synonymous with a filthy oracle of doom that spews forth death and plague. If you remember this, you might avoid the lament of nurses and scrub techs everywhere. But you won’t remember this. And even if you do, the only difference is that you will be an alien buffoon wearing a facemask. 
  3. Tie your mask tight but evenly. But not too tight. Okay, there is really no way around the fact that your mask will slip into an awkward, uncomfortable position early into your first surgery, and you will stand for over an hour trying to adjust your mask using only the muscles in your nose and lips. Important Note: you CANNOT touch your mask with your hands after you have scrubbed in. Such actions will call forth hellfire and gnashing of teeth. I spent my second surgery, a vaginal hysterectomy, with my mask slicing upward into my eyeballs for what seemed like 2 hours. After the first hour, I began to embrace the possibility that I might go blind, but at least I was preserving the sterile field.
So really, what it boils down to is if you can successfully play the role of surgical buffoon for your first few scrub-ins without getting too down on yourself, you will get over the hump and the OR might even be fun. You will screw up, get yelled at, have to scrub and re-scrub until your hands are raw, and sometimes want to stick your tail between your legs. But if you are lucky, you will not gouge out your eyeballs via facemask. Then perhaps you’ll retain just enough of your vision to witness future buffoons walk in through the OR doors.

Thursday, August 4, 2011

Introduction to Clinical Mediocrity

“Oh well.” The nurse midwife shrugged her shoulders and went on to see the next patient. I had to get out of there. I wasn’t proud of wanting to leave, because maybe I could have helped things if I had stayed longer. But with frustration stewing just beneath my smiling exterior, I felt like it was time to go. And it was time to go. I was only scheduled to be at the clinic until noon, and it was now a quarter past one.
“Can you please fill out my evaluation before I leave?” The midwife nodded, took a look at my form, and then made me read off each category, noting which grades I should check off for my performance. The print was too small, she said. I did it with a smile. “Grab some of my super-juice on the way out” she hollered from a patient’s room after we were done. I filled my cup with the green concoction that she had purchased from a health food store, took a few sips, and tossed the rest in a trash bin on my way out of the hospital.
“Oh well” is something you say when your milk expires. It is appropriate for lost pens and broken vending machines. “Oh well” is not something you say to a nurse after she goes sprinting out of clinic and hospital in hopes of delivering to a patient the prescription you forgot to write. There is nothing dismissive about providing substandard care. I wanted to trash "oh well" like I had trashed the super-juice.
For the most part, third year is exhilarating. You come home exhausted because you’ve emptied yourself into new experiences. You deliver your first baby, you perform your first Pap smear, and you see 19 cm tumors being dissected out of people’s bellies. The most frustrating thing about third year, therefore, isn’t the sleep debt you quickly accumulate, or taking call on weekends, or even the time you spend studying for exams on top of it all. I think the most depressing part is that long hours spent in the hospital will eventually bring you right up against the darker underbelly of medicine. The inevitable truth is that we will all see patients—people who lean on us—being mistreated, mismanaged, or sometimes even blatantly misled. I wasn’t exhausted when I came home from the clinic that day. I was furious.
I had spent the morning at an obstetrics clinic working with a certified nurse midwife and her team of two nurses doing routine check-ups on pregnant women. “You will be helping me with the computer today,” she told me after I introduced myself. I gave her an eager nod, “alright, sounds good.” It was only my second day on the new LAC computer charting system, and the electronic procedures were all foreign to me. But you learn that as a third-year student, the right answer is always “of course I’ll do that” or “yeah, that sounds good.” So I watched as the midwife saw her first patient while indicating to me which icons to click, what things to type, how to create and file new notes—stuff like that. Then she entrusted me with the charting.
Even as I settled into my role, I quickly realized some things were being overlooked. After interviewing one of our first patients, the midwife insisted that I include in my note, “no vaginal bleeding, leakage of fluid, or uterine contractions. Positive fetal movements.” This is a pretty standard review for all pregnant women—except in this particular interview she asked none of those questions. In my most pleasant tone, I piped, “Oh, did we ask the patient these questions?” The midwife looked at me incredulously, and replied “don’t you think she would have told us if she had any of those?” I nodded and kept my lips tight. Maybe the midwife’s assessment was fair. Maybe not. You learn early on in medicine never to assume, and I didn’t feel comfortable making even these seemingly small assumptions. I know enough to know that this is how you get in trouble. So my frustrations began to mount.
After we saw a few more patients, she began asking me to include in every chart that “patient was counseled on preterm labor precautions.” It would have been appropriate except that no such counseling occurred. I started growing uncomfortable with some of this. As a medical student, you are often so busy trying to learn the culture and practice of each rotation, you sometimes lack the time and insight to raise valid questions. And even if your wits catch up with you, your position at the bottom of the totem pole sometimes precludes you from wielding a voice. So you learn to choose your battles wisely—especially if they involve engaging a superior who is expected to evaluate you. In retrospect, I regret not asking the midwife to clarify what she meant by preterm labor precautions. Somehow, in the heat of learning a new computer system and working in a new environment, my wits just never caught up with me. Or maybe they were being drowned out by my own frustration.
Things got worse when a Chinese couple came into our clinic toward the end of the morning. They spoke Mandarin and I was excited to be able to communicate fluently with them. The midwife dove into the exam while asking the husband a few questions, because his English was marginally better than his pregnant wife’s.  I started translating and taking my own history on the side, taking joy in answering a few of their simpler questions in Chinese. As I flipped through the patient’s electronic chart, I saw stated in previous records that there was a prior complaint of green vaginal discharge. I turned to the midwife and asked if a pelvic exam would be appropriate to which she simply replied “well, she was given antibiotics last time so she should be okay.” No exam. No repeat culture. Not even a few questions regarding whether the patient was still having symptoms. Instead, the couple was ushered out of the room, and I was left to finish the charting. After a few moments the midwife poked her head back into our room. “Are you ready for the next patient?” I was ready to leave.
The next patient turned out to be the lady for whom the midwife forgot to prescribe antibiotics. The positive urinalysis results were lying on the desk beside the patients chart, and we somehow missed it. The nurse ran to the bus-stop and returned with the prescription still in hand. “Oh well.” I can’t remember exactly how I felt as I left the clinic that day, because my head was spinning a bit. I do know that my thoughts never mirrored the midwife’s flippant “oh well.”
It’s clear me that providing adequate care for our patients comes with a multitude of challenges. New computer systems. Large patient loads. Limited time. I knew this when I signed up for medicine. I also understand that at some point, I will surely do worse than forget to write a prescription. We train ourselves to avoid mistakes, but hopefully, we also train to own up to the ones we do make. I entered medicine because I felt it was a humane endeavor. But it’s also a human endeavor. It is not empty of error or devoid of tragedy. Even as such, my feeling is that we can always do better than “oh well.”

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