Acute Appointments Are Never Quite What They Seem

I've been seeing most of the acute same-day appointments at the clinic, and 95% of them are far more complicated than initially advertised.
Runny nose & sore throat turns into a 32-yr-old G4P3 at 25 +3/7 wks with a history of 3 c-sections, recent gastric bypass surgery resulting in vitamin B12 deficiency, preeclampsia in 2 previous pregnancies...and a positive culture for strep throat!  And did I mention allergic to penicillin?
Urinary frequency becomes a 34-yr-old female with uterine fibroids, polycystic ovarian syndrome with associated insulin resistance, hypothyroidism, and a recent history of endometrial ablation for menorrhagia who stopped taking all of her meds (except xanax!) and has been feeling the urge to urinate Q15 mins for the past 5 months
Abdominal pain is actually a 19-yr-old diagnosed with ulcerative colitis at age 14 who is starting to have frequent stools with blood & mucous after a year of remission without meds...and the nearest gastroenterologist is 360 miles away in Anchorage!
Foot pain is revealed to be a 24-yr-old woman with chronic arthralgia, a recent ANA titer of 1:40 in a speckled pattern and a family history of lupus, awaiting a referral to the nearest rheumatologist 2245 miles away in...Seattle! [maybe she'll let me accompany her to her first rheum appointment and I can check on my apartment and say hello to my peeps at Swedish?]

My Military Cheeseburger

I had my first cheeseburger from the hospital cafeteria today:

Not bad for $1.70...but I've been bringing my own lunch to work almost every day.  Most grocery items are readily available in Fairbanks, only slightly more expensive than Seattle with the exception of certain items like almond butter:

With the lack of sunlight in the winter season,  foods tend to be infused with vitamin D to the maximum extent of the law:

           

My cooking is limited mainly by the sad display of abandoned kitchen implements that came with my furnished apartment: plastic spatula, can opener, miniature cutting board, slotted spoon* (*currently being used to clear snow from the car).

I like to travel with a compact Wusthof knife sharpener if I'm going to be away for more than a month.  It seems less risque than attempting to stash a sharp knife in my luggage and getting tagged as a national security threat.  But alas, the knife in my apartment is cheap, unstable, serrated and very very dull.

I can tolerate a lot of things, but shoddy cutlery is not one of them.  I took a field trip to the cavernous Walmart on the other side of town--purportedly the largest Walmart in the entire country, where people come from all over Alaska to stock up on supplies.

I found a 5" Santoku knife and a 3" paring knife, both significantly more stable than the sad serrated knife in my kitchen.  The new knives sharpened up beautifully after a few rounds with the Wusthof. Now I can slice sweet potatoes without fear of dislocating my wrist.

Four Degrees Fahrenheit

The weather has been relatively mild (mostly in the 20s to 30s in daylight, dropping to the teens overnight)...until today when it was still only 4 degrees at high noon.  Yes, now I will admit that it's a teeny bit cold.  I've been told that the snowpack which has developed over the past few weeks will likely persist until May.  Luckily, Fairbanks has a crack snow-plowing team that seems to work round-the-clock.  Because Fairbanks lies at the bottom of the Tenana Valley, cold air tends to accumulate over the city. The average low temperature in the winter is around -25 degrees, but it has gotten as cold as -60 degrees in the past.  Being just 188 miles south of the Arctic Circle probably doesn't help.  What amazes me is that, despite the cold and the snow, many people still travel on bicycles--you can see bicycle treadmarks all over the sidewalks:

THE VIEW FROM MY WINDSHIELD
October 17:

October 23:

October 30:

Cleared and All CAC'd Up

I'm cleared to see patients!  Finally!  I've managed to score the following essential items:

1. Hospital ID badge with a blurry picture of me sitting in front of a huge American flag, clutching a tiny notebook filled with crib notes on how to navigate the clinic EMR system.

2. CAC (Common Access Card): a smart card issued by the Department of Defense with an embedded circuit chip that enables me to access the computer system, sign documents electronically, and send encrypted email...and BONUS: it also doubles as an identification card under the Geneva Conventions [...in case I get captured by the enemy on my way to work??]

Processing for the CAC involves the use of an optical fingerprint scanner on your right index finger.  Turns out that after 7 years of obsessive-compulsive handwashing through medical school and residency, my fingerprints are quite worn out.  The clerk had me try alternate fingers from my right hand: ring finger, pinky...all terrible quality prints.  Then, as a last resort...

Clerk: Can you place your middle finger on the scanner?                                         Me: Please don't tell the Feds I'm giving them the finger

Will my lack of readable fingerprints cement my future as a crime kingpin?  Stay tuned...

Sunrise Over the Hospital

The clinic is situated inside a 32-bed hospital, built in 2007 with a very sleek and modern look.  After entering the foyer through the first set of automatic doors, you are greeted with a delicious blast of heated air just before you step through the second set of automatic doors into the hospital lobby.  The patients are all military personnel and their dependents.

Most of the clinicians are also in the military; they wear army fatigues and combat boots in clinic.  I am extraordinarily jealous of their multifarious pockets.  I've never heard anyone addressed by their first name: it's always Sargeant B or Major V, or, in my case, Doctor or Ma'am.  The office that I share with Major V is haunted by a poltergeist who:
a) keeps the temperature rather chilly in contrast to the rest of the clinic which is reasonably warm
b) mischievously turns off the light without warning several times a day

The Alaska Railroad, which connects Fairbanks to Anchorage, runs part of its Denali Star route behind the hospital:

3 Levels of Classified

Classified information is rated as one of just three levels: Confidential, Secret, and Top Secret. Somehow I always envisioned a more complex hierarchy of progressively classified information: from nylon-static-cling Level 1 Confidential, to ironclad-amber-waves-of-grain Level 5 Confidential, all the way up to hermetically-sealed-and locked-out-of-my-apartment-AND-my-car Level 23 Top Secret.  My military issue laptop is unbelievably secure...so secure that I am not authorized to install my own office printer.

Maybe this explains why I've been here for an entire week and I still haven't been cleared to see patients [perhaps they discovered my overdue library book fine from 1994, or my occasional propensity for jaywalking...?].  I remain officially in Processing Purgatory.

We Use an Irritant Smoke

The Respiratory Fit Test
This is the rite of passage where you try on a special mask that covers your nose & mouth to make sure you have the correct size that will prevent you from inhaling airborne pathogens like tuberculosis or [insert your favorite airborne pathogen].  In all the hospitals where I've done rotations, an aerosolized form of saccharin is used to test the fit of the mask; if you perceive a sweet taste after the saccharin is sprayed, your mask does not fit properly. My fit test this week was conducted by an RN in the Occupational Health building.

Military Occupational Health RN: Most places use saccharin to conduct the fit test, but we use an irritant smoke
Me: What?!

It's true!  She was literally blowing smoke at me after I applied the N-95 respirator mask, and she had me turn my head in various directions, count to 10, and bend forward at the waist, all to prove that the mask fit snugly enough to prevent smoke from entering my airway.  It was after she allowed me to remove the mask that I was fully exposed to the "irritant smoke" and promptly launched into a prolonged coughing fit.  Now I feel like I have emphysema.

Snowfall

My weapon of choice for clearing snow off the car in the morning:

The slotted spoon is surprisingly adept at scooping out snow from odd little crevices in the region of the windshield, and there's something oddly genteel about wielding a spoon in the wee hours of the morning.  [Would you like one lump of sugar or two...?]

When I picked up my rental car at the airport,  the sales clerk handed me a blue extension cord and explained it was for the yellow plug protruding from the grille of the car:

    

The other end of the extension cord plugs into an outdoor outlet that is controlled by a mysterious red switch in my apartment:

   

Everyone's car in Fairbanks has an engine block heater that helps prevent the coolant around the engine from freezing overnight, making it easier to start the car in subzero temperatures.  The block heater has a plug extending out through the grille of the car so that it can be connected to an AC power outlet.  All outdoor parking lots are equipped with rows of power outlets for exactly this purpose, although it is tempting to imagine appropriating the outdoor outlet for a waffle iron or a toaster.

Prepared to Vanquish Fires!

Day 2 in Fairbanks: a very toasty 38 degrees. The apartment complex staff that I met yesterday was rather...eccentric. When I explained that I was scheduled to move in by my locums agency, she looked at me suspiciously and commanded, "Go stand over there", pointing to the farthest corner of the room as if I were a domesticated but still slightly dangerous grizzly bear that needed a time-out. I signed a ton of paperwork as she went over a zillion rules & regulations I was LEGALLY required to follow.

Most exciting part of the day: testing the fire extinguisher in my apartment (one of the LEGAL requirements). I released the fire extinguisher from its wall mount, pulled the pin and sprayed into the kitchen sink, releasing a high pressure gush of yellow powder which immediately coated the entire kitchen. Since I am LEGALLY required to NOT open the windows between the months of October and May (for fear of the entire apartment freezing into a solid cube of ice?), I had to settle for the fan above the stove.

Please Tone Down the Atropine

I think they overdid the dilating portion of my eye exam:

My Summer of Spectacular Slackerdom

After graduating from residency, I forced myself to put off finding gainful employment...because I'm a workaholic!  From the east coast!  With OCD!  
The early part of my laconic summer was spent designing and hand-sewing outfits for an asian baby doll that belongs to the 4-year-old daughter of a friend.  It was like a Lilliputian version of Project Runway, but without the backstabbing and smarmy comments ("That is so bridesmaid!"; "It looks like a disco straitjacket!"; "I question your taste level!").  My favorite piece is a set of miniature fairy wings I fashioned from an old underwire bra and some glitter.  I think Tim Gunn would approve:

My pack rat tendencies really came in handy for other intriguing outfits made from scraps of denim, stretch cotton, wool, and red velvet:

  

Sadly, my summer of spectacular slackerdom is coming to an end, and soon I'll be shipped off to a locum tenens position in Fairbanks, Alaska where the aurora borealis can be seen 200 nights of each year.

George Washington for Breakfast

3-year-old boy brought to the ED by his family after allegedly swallowing a foreign object earlier in the morning while learning a card trick at the breakfast table.  No airway difficulties.  He looks peachy, but the radiographic evidence tells a different story...

PA CXR: full frontal view of a round, radio-opaque object roughly the size of a quarter
Lateral CXR: the thin, round edge of the foreign object is seen lodged in esophagus

After a heroic extraction by EGD, a slime-covered quarter is retrieved and placed in a specimen cup.

Astute 7-year-old sister: Can we have the quarter back?
Father: [examining the loot] All this fuss over a Connecticut quarter??

Plastic Jesus, Plastic Surgeon

S: Adorable 2-year-old girl frantically rushed by her mother to the pediatric ER after falling from the top bunk bed while clutching a ceramic statue of the Virgin Mary. The statue shattered, slicing open the girl's right temple.

O: T 98.4 . . BP 85/50. . HR 115. . RR 24. . O2 sat 99%
5 cm laceration on R temple approximately 1cm in depth with no discernible ceramic fragments embedded. Subcutaneous tissue and temporalis fascia exposed. Bleeding well controlled [that is to say, until I started stitching...]

A/P:
1. Patient placed under conscious sedation with ketamine.
2. Laceration vigorously irrigated with 0.9% saline solution, sterilized with betadine, anesthetized using 1% lidocaine with epinephrine. Subcutaneous closure with 5-0 vicryl. Skin closure with 8 interrupted stitches of 6-0 nylon.
[Have you ever experienced the delight of using super super thin nylon suture the same color as your squirming pediatric patient's hair??? Exhale a little too enthusiastically and the suture blows all the way across the room. But the results were gorgeous. I could have been a plastic surgeon]
3. Mother advised to keep the wound clean & dry, have stitches removed in 7 days, and strongly urged to use plastic religious icons instead of ceramic.

Let's Order a Round of Pulmonary Emboli

Insanely busy day on call with rapid-fire admissions:

Admission #1: An affable 80-year-old man from a nearby island, s/p hip replacement surgery, on coumadin with a subtherapeutic INR and a right pulmonary embolus. We increase his coumadin, start him on lovenox and run off to...

Admission #2: A 53-year-old attorney recently recovered from a sprained ankle, admitted for chest pain and shortness of breath, found to have small bilateral pulmonary emboli. Really! Lovenox, anyone? Let's throw in some coumadin and a little oxygen by nasal cannula before we head toward...

Admission #3: A 27-year-old G1P0 who is 7 weeks pregnant with a cough and some swelling in her left calf. Are you kidding me?? She, too, has small bilateral pulmonary emboli in addition to a DVT in the left popliteal vein. More lovenox! (but coumadin is verboten, being a teratogen and all...)

I could horrify you with more sordid tales of admissions for pulmonary emboli, but let's quit while we're ahead, shall we?

All About Eve

You do not truly understand the addictive properties of heroin until you take care of a patient who continues to shoot up despite being hospitalized repeatedly for Strep viridans endocarditis, Enterococcus osteomyelitis, methicillin-resistant Staph aureus abscesses, HIV nephropathy, and a dash of Hepatitis C.

The social workers avoid him like the plague because of his outer coating of surliness. He rolls his eyes whenever you enter the room. He refers to his brilliant infectious disease specialist as "that Oriental dude".

But one day you catch him watching "All About Eve" on cable and he admits that he love love loves Bette Davis. A week later he describes an episode of "20/20" about Broken Heart Syndrome and wonders aloud if he has it after all the grief he's experienced in the last 2 years.

Soon you feel like an old married couple when you find him back in his room after an interventional radiology procedure, still wearing the bouffant scrub cap that resembles a glorified shower cap, eating half a watermelon with a spoon. "Look at my pee," he says, pointing to his plastic urine container. "Does that look normal?"

The next time he's admitted to the hospital, you breathe a huge sigh of relief when it's just run-of-the-mill community-acquired pneumonia.

Instant Partner Notification

Second rotation as an intern: ED
Lesson learned: Some of us need no prompting to talk to our partners

Patient in the emergency department: a young woman with RUQ pain, normal labs, normal ultrasound, and trichomonas found incidentally on UA. After explaining that she has trichomonas, that trich is an STI, and that she should tell her sexual partner so he can get treated too, I'm about to do a pelvic exam when she suddenly gets up, walks over to the phone with her IV trailing behind her, and starts dialing with murderous jabs of her index finger.

"Pick up the phone RIGHT NOW!!!!" she says emphatically into the receiver. "WHERE are you???"

Then apparently the person on the other end answers.

The patient says, "I just got the biggest shock of my life. They told me I have a sexually transmitted infection and there's no way I got it from anyone else but YOU."

Pause as the person on the other end speaks.

Then the patient interjects, "No, you SAW my test results. I showed YOU mine and you KNOW I was clean. I haven't been with anyone but you in the last 2 years. WHERE did I get it from? From YOUR contaminated ass!"

Tell it to him, girl! Notify his contaminated ass!

Never Turn Your Back on a Multip in Labor!

First rotation as an intern: OB
Lesson learned: Beware of precipitous deliveries from multiparous women!

Example 1: Woman, G4P3, being wheeled to L & D with intense contractions. Alarm goes off in her room, and I sprint over, only to discover 50,000 nurses crowded around her. The woman is still in the wheelchair and a head is coming out of her vagina! The nurses ease the woman onto the floor, the baby is delivered. Thirty minutes later, after we deliver the placenta and stitch up a second degree perineal laceration, the woman's chart is located. Under obstetrical history, it states the patient has a "history of precipitous deliveries x3". Ha! Make that x4.

Example 2: Woman, G2P1, with didelphys uterus and double cervix, arrives with her right cervix dilated 5 cm. After she has been registered and settled into a room, I leave for a few minutes. During the short span of my absence, her cervix has completely dilated and the baby starts to emerge--it's a footling breech! A nurse who happens to be walking by, notices what's going on, runs in and delivers the baby.

Example 3: Woman, G3P2, arrives in OB triage, moaning with intense contractions Q2-3 min. I check her cervix. She is complete/complete/+2. We wheel her bed immediately to L & D. She doesn't speak English but seems to understand my half-baked Cantonese. The OB fellow comes in and wants me to coach the woman through labor. I'm trying to tell her to "push like you're having a bowel movement" in Cantonese but I have a feeling that one syllable is off and I am mistakenly imploring her to "push like you have a big nose". Baby delivered quickly after 10 minutes of pushing, and luckily the real Cantonese interpreter appears. God knows I might have accidentally asked the father if he wanted to "cut the Empire State Building" instead of the umbilical cord.

For Everything Else, There's Mastercard

Total amount received in Stafford loans during medical school: $92,000
Amount spent on industrial size bottles of ibuprofen to ease the pain of being a medical student: $95.60
Having Arnold Schwarzennegar's signature on your University of California M.D. diploma: priceless

Of Pills and Pie

Wrapped in a protective gown with a mask obscuring half my face, I entered the isolation room. The patient was a frail 78-year-old man with marked temporal wasting and a worrisome cough. He had been transferred from another unit, labeled uncooperative and irritable. His sputum had tested positive for acid-fast bacteria, but he insisted he was not sick and refused to take any medication. Realizing that the patient resented being treated as if his illness was his one defining feature, I sat down and spoke with him about his life outside the hospital. He was a retired postal worker who had been widowed for 5 years. His favorite pastime was baking, and sweet potato pie was his specialty.

It was then that we struck a bargain: if I was able to bake a sweet potato pie that was as flavorful as his, he would take the cocktail of isoniazid, rifampin, ethambutol, and pyrazinamide.

When I went home that evening, I researched pie recipes with the same fervor ordinarily reserved for obscure medical conditions. With a combination of two different recipes and some improvisation, my pie was produced. The next day, I presented the sweet potato pie. The patient lifted a spoonful to his mouth. “Lemon juice… vanilla… cinnamon,” he murmured as he chewed. He closed his eyes and smiled. “I’ll take the medicine now.”

Recipe for Match Day

1. Alarm goes off at 07:00
2. Mix equal parts champagne and freshly squeezed orange juice into a 40 ounce industrial strength thermos. Pack 20 dainty Disney Dixie cups so that:
a) to the untrained eye, I will appear to be harmlessly sipping orange juice
b) I can share my homemade mimosas with classmates who are in close physical proximity and we can all appear to be harmlessly sipping orange juice
3. Arrive at our Match Day venue at 08:00
4. Pick up my pre-ordered personalized Graduation Announcements. Having been forced to purchase a minimum packet of 25 when I really only needed 10, will try to convince more popular classmates they can be ghetto-fabulous by taking my extra announcements, crossing out my name, and inserting theirs.
5. Pretend to listen politely while our endearing taskmaster of a Dean gives his rah-rah inspirational speech to 150 soon-to-be graduating medical students, all chomping at the bit to find out where we matched. We need ativan 1 mg IM Q1-2h prn agitation.
6. At 09:00, the Match Day envelopes are distributed; a wave of frenzied ripping-envelope-open noises reverberates throughout the room, accompanied by shrieks of excitement and/or dismay…
7. …and I got my top choice!!!!! Goodbye La-La Land, hello Emerald City!

My Life As a Dictator

There's nothing like being in a room full of attendings and residents who are all on the phone reciting succinct dictations that recount the clinic visits of their patients. Imagine people in white coats speaking quickly, crisply sotto voce into phone receivers as if it were the most natural activity.

I, on the other hand, feel like I'm having a coronary every time I start a dictation: face flushed, difficulty breathing, palpitations, chest pain, and the inability to form the simplest of words. My dictations are full of awkward pauses as I try to persuade the frozen peas of my 4th year med student brain to thaw out and justify my medical decision-making. I drop multiple apologies to the poor sap who has to listen to my stumbling dictation and transcribe it into a legible document. I live in fear that the transcriber will hunt me down in the middle of the night and swiftly dispatch a poison dart into my larynx as punishment for my sub-par dictating skills.

Report from the Battle of Normandy

The Interviews
15 total, about 2/3 family medicine and 1/3 emergency medicine with one combined FM/EM program. The two specialties are more similar than most would suspect. Both require a very broad spectrum of knowledge gleaned from multiple fields and the ability to quickly develop rapport with patients of all ages. With rising numbers of uninsured patients, a growing proportion of visits to the emergency department involve primary care related issues.

Hands-Down Most Bizarre Interview Question: What is the glue that holds you together?
Answer:….um….Elmer’s..?
[in a Monty Python world, the rest of the exchange would go like this:
Interviewer: Elmer’s School Glue or Elmer’s Wood Glue?
Applicant: School Glue
Interviewer: Wrong, it’s Wood Glue!!!!
Applicant: (screams while being jettisoned off the bridge into the misty swamp below)]

Toward the end of interview season, attention deficit disorder emerges and your mind starts to wander, fluttering around frivolous trivialities: Why is the Applicant from New Jersey so distractingly tan in midwinter? or Where can I score some tater tots and a gin & tonic?

The Travel
6 flights, 5 rental cars, numerous road trips in my trusty Honda Civic, 7 hotel rooms, and several episodes of bittersweet chocolate intoxication. On the flight home from my final interview, while I drifted in and out of sleep in a haze of Sudafed (phenylephrine formula, not the good stuff with pseudoephedrine) and Halls menthol cough drops, the plane hit a patch of turbulence and was vigorously tossed in multiple directions.
Other people on the plane: Are we going to crash?
Me: Am I going to sustain a head injury and fall into a coma without submitting my rank order list?!

The Rank Order List
Medicine, being full of obsessive-compulsive types, loves lists. Applicants submit a list ranking the programs they have visited. Residency programs submit a list ranking the applicants they have interviewed. While creating the rank order list, applicants can omit programs they don’t want to attend; residency programs can omit applicants who are unacceptable to them. Everything goes into a giant centralized computer that runs a complicated algorithm multiple times during the 3 weeks between the rank order list deadline and Match Day. Why? They say it’s for quality assurance; I say it’s for pure, unadulterated torture. On Match Day, we each get an envelope with a sheet of paper that tells us what residency program we’ll be attending. And yes, it’s a binding contract, people. Run for your lives!

Trannies, Brought to You by...the Feds!

Anesthesiology elective at the VA: We're in the OR, and the next surgery is a bilateral breast augmentation...the patient is a male-to-female transgender currently on hormones.

Within the span of just one hour, the plastic surgeons give the patient some fabulous 330cc silicone breast implants (a C cup in non-medical speak). The patient had requested the 450cc implants (a D cup), but his/her anatomy didn't allow for implants of that size to be inserted. It was difficult enough getting the 330cc ones in.
[plastic surgery intern: Why don't you just make the incision bigger?
senior resident: Because then we wouldn't be plastic surgeons!]

As the surgeons are completing their closing sutures, various nurses and doctors keep sneaking into the OR to peek at the final product. A scrub tech gently squeezes one of the newly structured breasts to get a sense of the texture. Transferring the still-anesthetized patient onto the guerney, some of the staff note his/her hot pink panties; they peek underneath the panties to reveal a very well done gender reassignment genital surgery.

Imagine, the feds are actually footing the bill for this stuff! Who says the government doesn't take care of its veterans...

Mucho Mucho Dolor

You do not know the true meaning of pain until you find yourself in the middle of a subinternship in the high risk obstetrics ward at a posh private hospital. Imagine your chief resident is a puffy-faced fascist named Satin (he pronounces it sa-TEEN, you prefer to pronounce it satan) who revels in terrorizing medical students. Your patients are upper crust ladies on complete bedrest, seething with hormones, bellies growing with multiple gestations courtesy of in vitro fertilization. They bring their own private masseuse, pedicurist, manicurist, gourmet chef. They hate you. They demand to know why you and the nurses keep barging into their rooms to take vital signs, manage fetal monitoring, check on their preterm contractions [Newsflash: This is a hospital]. You are looking at your watch and counting down the days until graduation.

Someone comes into labor & delivery, insistent on having a Silent Birth. Scientologist? Perhaps, but after 20+ hours of failure to progress, what she ended up with was a Silent Caesarean Section.

Eggs on Toast

Two jumbo grade AA eggs were prepped and draped in the usual sterile fashion. The eggshells were cracked against the rim of a 0.75 quart stainless steel mixing bowl, releasing the albumin and yolk directly into the bowl.

Albumin and yolk were beaten until frothy with an 8" stainless steel whisk, then poured into a warmed and oiled 11" cast iron skillet. The eggs were scrambled until fluffy, then sutured to a waiting slice of freshly buttered toast using a horizontal mattress stitch with 3-0 absorbable chromic gut. Meticulous hemostasis was obtained. Salt was then applied. The eggs tolerated the procedure well.

Dish towel, spatula, and knife counts were correct x2.

Let Me Clinically Evaluate You

What It Says: This student completed a 4-week clerkship on our service. Her performance was satisfactory.

What It Really Means: Was this the short one, the one with glasses, or the one who attended every conference where food was served? I don't recall spending more than 5 minutes with any of those pesky med students...

What It Says: The student was attentive during rounds. Her fund of knowledge was average.

What It Really Means: Where's my Rolex? Did it fall into the surgical field during that last exploratory laparotomy?

What It Says: Her attitude and enthusiasm need to improve. She certainly would have learned more if she had read more.

What It Really Means: All this writing is making me hungry. Where's that steak I ordered?

Evil Mollusk Has 2 Pimps

One of the mainstays of medical education is a process colloquially known as pimping.

There is good pimping and bad pimping. In my unscientific, unrandomized, and noncontrolled trials thus far, the bad pimps seem to outnumber the good pimps by 3 to 1.

Good pimping: Your pimp asks you questions with the intention to teach, helps you hone your critical thinking skills, broadens your understanding, helps you realize you know more than you suspect. You learn to approach relevant medical questions systematically with purpose and focus.
Example: Right after the baby has been delivered, umbilical cord clamped & cut
Question: What are some signs that the placenta is ready to come out? Answer: There's a gush of blood...the umbilical cord becomes easier to pull...
Question: Why would the uterus feel globular at this time? Answer: It's contracting in order to dislodge the placenta.
Question: Why is it important to apply suprapubic pressure while pulling on the umbilical cord? Answer: To prevent the uterus from inverting as the placenta comes out.

Bad pimping: Your pimp asks you questions to humiliate or fluster you, or to show off how much they know. They rattle off a barrage of random and obscure questions that are not helpful.
Example: a neurologist who favors flagrantly esoteric questions about rabbit experiments that are in no way related to the patient you are discussing.
Question: In the seminal [insert name of famous neuroscientist] experiment of 1974 in which EEGs of rabbits were recorded, what was the most common waveform? Answer:Uh...with all due respect, sir, most of my patients are humans.

Holy Carnivorous Cajuns, Batman!

Scene 1:
I'm all dolled up in a sterile gown and my size 6-1/2 sterile gloves. It's the first time I get to use a scalpel (#15 blade), a bovie (for electrocautery), and sutures (3-0 chromic gut with tapered needle) all in one procedure. And the body part in front of me is...a PENIS!

A collective shudder is palpable among the males in the OR. Our 45-year-old patient requires a circumcision because he has developed phimosis & cannot get his foreskin to pull back.

Male scrub nurse: I'm so glad my parents had me circumcised when I was a baby!
Male urology resident: Ditto for me!

Scene 2:
The patient is resting in the recovery room.
Urology resident: The procedure went very well, and you'll be healing nicely in the next couple of weeks.
Patient: Did you make it bigger?
Me: That costs more!

He nicked The Ureter

In the realm of gyn surgery, The Ureter takes on almost mystical significance: Muscular tube just 3 millimeters in diameter! Propels urine from kidney to bladder! Runs precariously close to the uterus! The Ureter can easily be nicked by an overzealous surgeon during procedures such as hysterectomy.

I can't think of a single intraabdominally-approached gyn surgery in which an attending did not pointedly remark, "Look, [insert medical student's name], there's The Ureter".

Enter Dr. Austin Powers, International Man of Self-Aggrandisement. All pimped out in wool crepe trousers decked with sky blue pinstripes matching the precise hue of his Egyptian cotton shirt. Pimp Daddy. Pimpmeister. Pimp-o-rama-ain't-no-drama-wit'-yo'-mama. But I digress.

Long story short: he nicked The Ureter. No one said a word. If a resident or an intern had committed this folly, there would have been sharp reprimand and serious retribution. Instead, a SWAT team of urologists descended upon the OR and everyone donned lead-lined vests for the fluoroscopy-guided repair.

There was no further mention of the incident with The Ureter. His lecture on female pelvic anatomy was subsequently cancelled. Rather fortunate for me, as I would most likely have succumbed to my irrepressible urge to display this:

Contaminated

"You're contaminated!" says the OR nurse as my double-gloved fingertip accidentally wanders one centimeter south of the top surface of the operating table. She banishes me from the OR and I am relegated back to the scrub sink, destined to begin the elaborate scrub ritual once again. I start cackling inexplicably as I recall a streaming instructional video detailing the mysterious nuances involved in staving off contamination before surgery. You start with the requisite scrub brush, hermetically sealed in a little plastic package and permeated with the industrial cleaning solvent of your choice: povodine iodine, extra foamy soap, or the strange red stuff that resembles sweet & sour sauce. After scraping under each fingernail with the plastic stick, you scrub the tips of your fingers with the brush side (30 circular motions for each hand). Only then can you advance to the spongy side and start the serious scrubbing.

There is something uncommonly obsessive-compulsive about surgical scrubbing. Each finger has 4 planes, and each plane must be scrubbed 20 times. The palm of your hand has 3 planes, each of which must be scrubbed 10 times. Your forearm is divided into 3 parts, each of which is also scrubbed 10 times. Is the American Psychiatric Association aware that surgical scrubbing falls under the definition of compulsions as repetitive behaviors (e.g. handwashing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly?

I am tempted to make an anonymous phone call (handkerchief placed over my mouth in order to disguise my voice) to the Obsessive-Compulsive Disorder Police to turn these people in. For the sake of their mental health, of course.

"You're contaminated!" says the OR nurse as my double-gloved fingertip accidentally wanders close to the imaginary line extending from the sterile blue drape behind which the anesthesiologist is seated.

Bite me.