The Staff Who Steps Up

 Doing cataract surgery with a resident who is just starting out is surely a very stressful thing for the attending. The patient may not even belong to the attending - they're just here to oversee the care. But there comes a certain time when as an academician, as a teacher, you have to step up and be there for the resident.

I had a patient come to the pre-operative holding area one morning in preparation for his cataract surgery. Despite being told multiple times by multiple people to stop his aspirin a week before the surgery, he didn't to it. We always discuss with our patients, as residents, the use of blood thinners, primarily because in preparation for the surgery we give a retrobulbar block, the biggest risk to which is hemorrhage. But on aspirin, this risk is fairly low. And in the "real" world, a cataract surgeon may not even blink an eye about a patient being on aspirin.

OR, they change their game plan. Doing an anesthetic injection behind the eye (the retrobulbar block) is only one option for anesthesia. The other is simply using topical anesthetic with maybe a little bit injected into the eye. At my stage of training, many of my current attendings would have just cancelled the case - sent the patient all the way back home, only to have to reschedule and repeat the whole process, costing everyone more time and money.

But I was lucky enough to have an attending that day who stepped up. Everyone else would have cancelled the case. But he walked up to me, handed me the appropriate topical anesthetics and said, "We're doing this one topical. See you back there."

That about made him the best attending to do cataract surgery with.  I think.

The Consultant's Magic Words

As ophthalmologists, a surgical subspecialty, we are consulted a lot. As ophthalmologists in an academic center, we are consulted far more than is appropriate. And because we're residents, consults are frequently downright abused.

The fact is, people have learned the so-called magic words which buy a guaranteed-to-see consult. Even if it means the story is grossly exaggerated, if it gets the patient seen that day, that's all the consultee cares about. Of course it's not like this happens all the time, but there are a few key examples.

"It's a painful eye."  I have been told this before only to find out from the patient that, in fact, there was no pain at all. "No, Doc, there's no pain. It's just that I have had this bump on my eye for a few months and decided to come to the ER at 5 PM on a Friday. Gee, I'm sorry you had to work me in for this." Yeah, right.

"The vision is worse than before."  I have been told this before only to find out from the patient that, in fact, the blurriness is only when they first wake up and it goes away after a few blinks. "Oh, and let me guess, you're having eye pain too, right?" "No, Doc, just a little fuzzy after I intensely rub my eyes in the morning. Should I sleep in my contacts?"

Don't exaggerate just to get us to see the patient. It doesn't make you look any better to me. And I will be sure your attending doesn't think better of you for it.

Yes, I Worked Through Lunch

It has not happened recently, seeing as I have been at JEI and ACH lately, but yes, sometimes I have to work through lunch.

What's funny is that some patients, should they come to find out this little piece of information, show a fake sense of sorrow about it. We all know that if they saw me walk by with lunch in my had, they would grumble about their "prolonged" wait.

"Oh, you haven't eaten yet?"
"Why no, I haven't."

For some reason, this is not a subject I like to discuss with patients. It's on par with discussing my age. I am not sure why this is, but it is. Maybe it is because lunch is that brief period of time during the day, even if only for five minutes, when my obligations to the patient population are nil. That is my time, whether I choose to spend it alone or with my coworkers. Or sitting on the phone with my wife. Or running a quick errand to the post office.

I don't ask you about your age or lunch break, so please feel free not to ask about mine.

The Apparent Stigma of Pink Eye

I find it somewhat comical when a patient comes in to the clinic with a routine case of pink eye. Well, not funny that they have pink eye, but how it is often dealt with.

The first thing they do is put up a thick wall of defense. They come in knowing their eye is red and irritate. But there is no way in hell they have been doing anything that would give them pink eye. And so when I bring this up as a possibility from the get go, not long after entering the room, it's as if I have accused them of something dirty. It seems as though this disease is put on par with the clap or something. Then there is this wave of depression or let-down. I've told patients they had cancer and had them handle it better sometimes. Sometimes not.

Well, I don't know where it is you're putting your face, but pink eye not any different from any other infection. I suppose it has something to do with the fact that everyone can immediately tell you're "infected," whereas other infections may require special privilege to know about them.

Update

So allow my to apologize for a little bit of a hiatus there. I have been quite busy with a number of things: writing a paper, trying to polish up an IRB proposal (over and over and over and over), and oh yeah, gathering everything needed to apply to fellowships. I have had a little stress to say the least, and although I enjoy writing here, other things just needed to take precedence.

That paper is more or less finally written. It has been rewritten more times than I can count. All that's really left is going through the arduous process of submitting the whole thing online. We'll see how it goes.

The IRB proposal has been a learning experience for more people than just myself. Starting a prospective study from square one is not something many people at JEI are familiar with. In fact, practically no one is. I have had to have multiple meetings with multiple people just to figure out what might fly. We shall see.

Then there has been the application process. The amount of redundancy has been sickening. Assimilating the information was probably ten times more work than it was for residency - even though the exact same centralized application service is used for both. Where's the trust?

Anyways, as I promised a mentor, here is a plug to his newly begun blog:
http://eyelidsurgeon.wordpress.com/  He has several posts about the do's and don't's that people in the real world care about. Check it out - he is looking for more hits.

Allow Me to Draw My Condition For You

It is no secret that some of our patients border on crazy. Fact is, there are psychiatrists to manage the crazy people. When a crazy person walks into my clinic I am not always sure what to do.

So one day this, you got it, crazy guy comes into my clinic room. He brings in with him a large bag stuffed to the max with categorized folders documenting in detail his prior physician visits. This, off the bat, is never a good sign, if not always a bad one. Seeing as I was new to him and he to me, he began at the beginning, some years ago. But it wasn't with words. It was with pictures. He had drawn out in detail the visual distortions he noted in his vision. Each complete with color coded documentation.

Right off he clearly doesn't understand how unimportant all this stuff is. Of course, he then proceeds to tell me that no resident in the past was ever capable of seeing his problem, only the retina attendings. "Okay," I'm thinking at this point, "this guy is in for it." Even from his story it was obvious he had categorized residents and attendings on opposite sides of a tall cinder block wall. He was missing out on key elements of the resident-attending relationship that are quite obvious to others.

"Look, any new problems today?" I asked
"Well if you'll give me a piece of paper. . ."
"I'll just go get the 'Retina Specialist.' Draw while I'm gone."

Drawing is a true art. But then, so is knowing how to cut people short in their graphic rambling.

Moving From a Frustrating Case to a Satisfying One

The best way to make use of operating room time, particularly in an specialty where operating days are limited to one or two (or three) a week, is to schedule all cases at that same time. Then you spend the morning going straight from one case into the next, hopefully getting yourself into a good routine. But as a learning surgeon, the inter-case variability may be significant.

One morning I was doing a cataract case during which it seemed like everything became ten times more complicated than they needed to be. Ultimately, the patient did just fine and in the end the surgery could easily be considered a success. But the path to that end was very rocky and difficult. This is never how you want to start the day; it seems to set everything else off pace and it can be very difficult to get back into a good rhythm.

Then my second case came rolled into the operating room. Somehow, things went just splendid - if not a bit longer than what an experienced cataract surgeon may take. Suddenly, it seemed as though the day was going to go okay.

Time to Take the Eye

An enucleation spoon, believe it or not

As eye doctors we have this goal through training that ultimately results in saving vision and protecting the eye. But there are times when instead of keeping a bad eye, the best thing we can do for a patient is get rid of the eye. This is a process called enucleation, and while it's a generic procedure name many specialties use to refer to removal, it means only one thing to all eye doctors.

We recently had a patient who developed an infection in the eye. I happened to be the one to see him first on his visit to the emergency room with severe eye pain and redness. The infection was obvious and he as admitted for treatment. Several things, including surgeries and injections into the eye, were tried to save his eye. But ultimately, the pain and discomfort of a now blind eye became too great.

Only after removal of the eye did he completely turn around and become his old, easy going self.

Regenerating Hope

 

You're Not in the Club!!

I may have mentioned before how there is a club to which certain oculoplastics fellowships belong. This is known as ASOPRS, or the American Society of Ophthalmic Plastic and Reconstructive Surgery.  What does membership mean? Perhaps a bit more prestige in the long run and maybe a better academic appointment if that is desired.

So here is the plan. I will first apply to the ASOPRS programs simply because the application deadlines for those are first - the match occurs this coming April. If/when I don't match via this route, I will then seek out the non-ASOPRS fellowships and apply to those who are willing to take on a fellow in 2013. It's basically about putting myself out there and seeing what grabs. They typically interview only 8 months prior to the start date.

The fact is, of all the people who apply for ASOPRS fellowships during this match cycle, only 50% or less will get a spot. The remaining half who don't match will consist of a couple different types of people. One type is the one who isn't terribly serious in the long run about oculoplastics and will ultimately decide to apply for a different type of fellowship. I used to be this kind of person - I thought if the plastics thing didn't work out, I would go the cornea route. But after much reflection, I decided I just wouldn't be overly happy doing cornea. The other type is the one who will reapply and find these other non-ASOPRS people. That's how both of my current mentors did it and they're both great at what they do.

What's to lose? And if a few years lapse between finishing residency and landing in fellowship position, so what?

That Question Wasn't Directed at You

So for those who visit regularly, you know I generally enjoy teaching - one of the big reasons my eventual plans are to enter as an academic surgeon. Having students around is usually enjoyable to me. But there are always those few students who are incredibly annoying. They come in several different types. And, hey, you can't expect everyone to like and enjoy everyone - it's just not reasonable.

We were all sitting in grand rounds one day. The third year medical students currently on the neurology/ophthalmology rotation came strolling in - late as usual, though not entirely their fault. Our grand rounds typically involve a lot of question asking of the residents - known affectionately in our field as "pimping." Although, the pimping at our program is pretty mild. At any rate, the questioner that day was not directing his questions openly; rather, they all started with, "Dr So-and-So, what is. . . ." This is all fine and dandy - it eliminates the type of silence where everyone is thinking: "Well, someone else will answer the question. I think. Do I even know the answer?? What if I'm wrong. Oh God, now I definitely won't answer. . ."

Well there was this medical student. Not even particularly interested in ophthalmology as far as I know. Any low-ball question that was asked to Dr. So-and-So, he was sure to blurt out the answer.

It didn't matter if he was correct in his answers. The temptation to slap him was overwhelming. I don't recall being like that as a student; I knew my boundaries. I think he will find himself having issues with this now and in the future.

A Dream About Failure

Anything surrounded by a lot of thinking and worry can be expected to be accompanied with dreams from time to time. The quickly upcoming stress of applying to fellowships has led to such a thing.

The other night I had a dream I was interviewing for fellowship somewhere in the Pacific Northwest (there are a couple potentials in the area). Through an arduous process of elimination, the applicant pool had been narrowed down to just me and another female applicant - a completely made up person in my head. Someone once told me that the faces we see in dreams should always be from someone we know; this is complete bollocks.

Anyway, she interviewed first and I second. At the conclusion of the interview, the physician (also someone I have never seen) across the table from me looked up and said, "I just don't think you're who we're looking for here." I exited the room only to find everyone applauding for the other applicant who of course got the position. I can't figure out who all these people applauding were. They weren't there when I entered the room, and why would they be so damn happy? I have never placed a lot on the "hidden" messages of dreams, but I mean what the hell?

On the upside, one of my fellow junior residents was there and was given (by the stranger interviewing me) a card - a free pass if you will - stating he would be granted admission into whatever kind of fellowship he wanted when it was his time to apply. Or, at least I guess this is an upside. Either that or a fat slap to the face.

A Tick in the Eye

In continuing with the tick theme as noted in a recent entry, I wanted to share this other tick story with you. Perhaps if I had gotten my sign up. . .

So this dude presented to the to emergency room (thank God it was during daylight hours) stating he has had something in his eye since the day before. He had been working outside and couldn't place anything as going into his eye. Naturally the emergency room immediately punted to us without an eye exam.

The eye looked pretty good at the surface. But further inspection with flipping of the lid revealed a moving target. Usually, a tick on the eye bites and latches on tight - much like skin. But this guy was moving, trying to avoid the giant approaching Q-tip. A single swipe and he was out of there.

Is there anything we can do that doesn't require the use of safety goggles?

Connecting On a Different Level with the Surgeon

I have only recently truly appreciated the different depths of a given clinical teacher. People behave, and apparently teach, very differently in different environments.

So, yeah. Learning from someone in the operating room is totally different than learning from the same person in the clinic.

Pretty much lost the rest of my thoughts on this one. Don't know what happened.

Those Little Gray Spots

You know what's scary to me? Children admitted to a psych ward. I have always felt uncomfortable in that situation. But do you what is even scarier? A KID IN THE PSYCH WARD WITH GRAY SPOTS ON HIS EYES!!!! AHHHH!!!!

Allow me to clarify a little bit while giving a lesson on time awareness. There was a child (yes, admitted to the psych ward) who fell while jumping on the bed. (Immediately I think of my daughter's feigned attempts at singing "No More Monkeys Jumping on the Bed.") Now, I am only being a little cynical by wondering why psychiatric physicians aren't able to assess someone after s/he fell to determine if head CT scanning is needed. After all, I have several friends in the department. But why they have to call a family medicine resident to do the assessment is confusing, if not concerning. At any rate, one did. And this one, we'll call him Dr. Thybeorver, noted gray spots on the kid's eyes. But even he knew this was not likely to be urgent and could wait until morning. Although, he still recommended an ophthalmology consult which was not needed.

Apparently, someone else (the psych resident) thought 5AM was a good time. "Non urgent you say? Well 5AM will do just fine, then."

Blah. So I saw the patient and of course agreed, there were a few perfectly normal looking gray spots on this kid's eye. Had probably been there since birth.

I got so scared I about shit a brick.

You Sound Like Tom Cruise

The comments regarding my overly youthful appearance are always forthcoming. And I can't say they disappoint me - I would rather look ten years younger than ten years older than my current age.

Some have commented on a particularly soothing voice. I have had one attending say I sound like a radio announcer. Although, I will claim to have led a more straight and narrow path than the Ted Williams with the "golden voice."

What took me by surprise one day was a little black lady who told me I sounded like Tom Cruise. How she really knew what he sounded like is beyond me. Perhaps she saw in entirety his little freak out moment on Oprah one day. Never once did I get on my chair or desk and jump around though.

So that's it. I am an 18-year old radio announcer with Tom Cruise savoriness.  With emerging gray hairs. It just doesn't all add up.

Look, a baby tick!!

The VA clinic is a very busy place. There are distractions everywhere. The halls are lined with people and each of the rooms experience constant in and out traffic. But once you're in my room, you expect my full undivided attention. Likewise, I expect yours. There is already a sign on the inside of my door telling you of the importance of not talking on the cell phone while I'm in there.

But I didn't think I needed a sign for this. A lady, perhaps more accurately a less than well-kept female, was sitting in my exam chair. She asked me some question about her glasses prescription. I then proceeded to tell her why we couldn't give a new prescription at that time (certain conditions preclude giving a good, accurate prescription). I did not have her full attention; to this day, I'm not certain I had much of it at all.

She was too busy examining herself. I think she was doing everything possible short of stripping to find what was bothering her. Recall I described her as less than well-kept - stripping was not an option. Eye contact could not be maintained. Then she found it.

"Oohh - a baby tick!" she acclaimed. "I was wondering what that was. . ."
"That's great. Don't throw it on the floor, please."
"I'm sorry, Doc, what were you saying about my glasses?"

Okay. New sign. Here it is:

The Lady in the Scooter

I know I have made an Austin Powers reference in the past, but I couldn't help but smile to myself and again think of that silly man when I saw exactly what this title implies.

You all know this scene. In an attempt to turn his little cart around, he wedges it between the hallway walls, switching from forward to reverse gears repeatedly to move mere inches.

Well, a lady at the VA did a very similar thing. Lots of those folks have found themselves in a powered scooter for one reason or another. Some have also become quite adept at maneuvering through the hallway; others not so much. This poor lady found her self similarly wedged in the hallway, except the effective walls were patients in chairs, each fiercely protecting what toes they had left (diabetes runs rampant in the eye clinic).

So what if I chuckled? There wasn't much I could do to help.

Look Mia - A Video Tape

As residents, we make video documentation of most if not all of our cataract surgeries and anything else that may be done under the scope and worth recording. At the VA, the current recording systems use VHS tapes to record the material. I have heard a DVD system was once tried but worked miserably with poor quality. Hmm, I wonder. . .

While we could speculate all day about why that may be, that is not the point of this writing. The point is, look at those things. Finding them in the store means looking at the bottom shelf nested back in the corner somewhere. Finding a player means going into your back bedroom closet with a shovel and a trash bag. And while that just sounds like a murder scene, it's to rid yourself of other useless junk while you're at it.

She only knew that it was a tape and was probably best served by lying on the table. But that DVD? You bet she knows what to do with that.

The Chief Race

At the VA, we are kind of in this position where we are between real chiefs. We have had acting chiefs, or people working in the chief position though not officially named. The way I have seen it, there seems to be two people currently in contention for the spot. The reality is, I didn't think either of these two people would have wanted such a thing; one has a few very little ones at home to help tend to, and the other seems to get way too stressed out over the little things.

Regardless, the VA now has a new surgery chief. Which means the decision process has only just begun - even if it already had several months before with the interim chief. Each of our two candidates serves as an ophthalmology chief for a period of time. Then it seems a winner will be chosen by the surgery chief. It almost seems like a season of Survivor.

I haven't been asked to be on a tribal council yet, but I'm sure it's coming. Look for us on the next VATV Morning Edition.

The Value of Patient Positioning

I should first point out the fact that though I have rotated over the childrens hospital as of September first, I often have a backlog of blog entries to write. I have been averaging in the range of twenty at any given time. And since I have only been averaging about fifteen posts a month for the last three or so, well, you do the math.

One of my biggest mantras has always been about the importance of proper patient positioning during surgery or a procedure. Firstly, we do a lot of our surgeries on patients are still awake, perhaps just a little sedated. Of course, I do want to go into oculoplastics where there are more patients who are put under general anesthesia. At any rate, you want them to be comfortable so that they can lie there still for a good period of time.

Secondly, the person doing the surgery has to be comfortable. Imagine trying to do an entire surgical case straining your neck to see through the microscope or hunched over because the bed is too low to the ground. These situations make for a very unhappy surgeon at the end of the day and may even cause chronic back and neck problems.

So if there is one thing I always tell to people when I am teaching is to get everything set up so that everyone is comfortable FIRST, then you may proceed. And this goes for everything form an exam at the slit lamp to putting in a central line to doing an 18-hour muscle flap procedure.

The Post-Op Hug

Who said hugs aren't nice. . .sometimes?

Cataract surgery has turned out to be a truly gratifying experience - and I think it's so for both the surgeon and the patient. In the academic and VA world, patients with cataracts have usually been walking around with them for quite some time. So by the time they present to us for the discussion about taking them out, they are usually fairly advanced. They have long lost their 20/20 vision, their sense of the color white is forgotten, and they can't remember the last time they were able to drive at night. It's different in the private world where patients have money and time and ability to keep regular eye appointments and cataracts are discovered and operated on early - though sometimes too early.

At any rate, for my patients, the difference between their preoperative vision and their postoperative vision is usually quite large. I've had some who couldn't even see the big "E" on the chart who now see 20/20 without any glasses. And even if we don't get to that perfect target, the vision is still far better, clearer, and brighter than before. Sometimes they are so thrilled, they can't help but hug me. I don't know that anyone ever hugs the surgeon who takes out an angry appendix; but cataract surgeons are frequent receivers of the post-op hug.

And that defines gratifying if nothing else does.

What I See in an Ambulance

As a medical student and even as a medicine intern the things I thought when I saw an ambulance were quite different from the things I think of now. It used to be we just affectionately called the ambulance a "whaambulance" in reference to it's most common passenger: someone without a real medical emergency.

Now, and especially the days I am on call, I will be driving home on the highway and see an ambulance headed the opposite direction. All I can think is, I hope that's not a trauma with facial fractures and an open globe. This may not be the best way to think of them, but I do.

Adjusting My Volume

Get the reference??

Something quite humorous happened to me in clinic the other day. I am currently seeing patients on a daily basis at the VA - the hospital for the veterans, for those who don't know. This is largely a population of patients 60 years old or older, usually with a list of medical problems with accompanying medications longer than the LOTR roll call.

At any rate, one day I seemed to get a particularly long stream of near-deaf patients in my chair. So over and over again I was doing nothing short of yelling at my patients, probably driving the patients and physicians in neighboring rooms to question my ability to establish good rapport. The patients in my room, however, knew no different. In fact, for some of them, I was doing little more than whispering.

Then a patient with normal auditory function stepped in. But I didn't know this at first. I had found myself stuck in volume-to-eleven mode and began yelling to him.

"HOW ARE YOU TODAY, SIR?"
"Fine. By the way, I may be near blind, but I'm not deaf."

I couldn't help but look at the floor and silently laugh. It's not like he could see me anyway. (Actually, he was nowhere near blind).

Some Basic Anatomy, Doc

Most of the people I come into contact with in a medical setting, at least on the doctor-to-doctor front, know their basic eye anatomy. Most nurses as well know at least the information on this here diagram. Now, I know the exposure to ophthalmology type stuff in most medical school curricula is limited. But this is basic anatomy - first and second year student material. Most learn this to a limited degree well before medical school even starts. Allow me to say that I would never expect the primary care doctor to know the eye and orbit anatomy as well as my mentors (I can't say "me" because I'm still learning). But something must happen when certain people graduate - any knowledge of the eye just leaves.

The example is when I was recently consulted to see a patient in the pediatric emergency room. I was told over the phone that the iris was lacerated from a stick injury.

"Okay, so you're telling me there's an open globe, then?"
"No, Bradley, the iris is just lacerated."
"That by definition, Dr. Wuposnockee, is an open globe."
"But. . ."
"What's the vision?"
"Well it's 20/20."
"You're telling me the patient had a stick go through the cornea, lacerate the iris, and yet the vision is perfect? The patient doesn't have an open globe, or an iris laceration."
"Well than what is it?"
"I'll tell you after I see the patient. . ."

The cornea had a scratch on it. Yep, he did just fine. I once had an open globe myself, and as minor as it was, I had nowhere near 20/20 vision. My iris was not even lacerated, by the way.

Call Before You Send it My Way

There are a lot of things that get sent to us from other areas of the state to take care of. A good deal of it occurring on nights and weekends does so because some local eye doctor is not available (or more commonly doesn't want) to take care of it. But that is for another discussion entirely. There is another group of things that get sent to us because others just don't know what to do about them.

I am happy to help take care of anything that someone else may have a question about. But there are certain times when that help should more appropriately be provided over the phone. There are clearly times when the patient just needs to be sent to us - the trauma patient, the patient with the orbital abscess, etc. But here are a few that don't

The shingles patient. A patient shows up to your emergency room or your office with shingles involving the same dermatome as that involving the eye. Does this patient need an eye exam - yes. Does it need to be done three hours from home in the middle of the night - absolutely not. This has happened more than once. The patient got sent inappropriately for an eye exam in the middle of the night. Had someone taken the five minutes to call me and ask about this, the trip could have been avoided. Because, guess what? This is not an eye emergency - I could have told them to come the next day. Or better yet, see someone local after the sun came up.

The conjunctivitis patient. This can always wait until the next day. To top it off, never, EVER, send these patients by ambulance or helicopter (which has been done!!) for a viral illness we will treat with over the counter artificial tears.

Above all else, if you're sending a patient to me specifically for specialized eye care, it's common courtesy to let me know about it ahead of time.

Please Don't Shake Your Baby

One of the less-than-satisfying tasks of being an ophthalmologist is getting that call from the pediatric intensive care unit after a child suspected of being abused is admitted. One of the routine exams performed in such a case is a dilated eye exam. Certain findings in the retina used to be a gold standard in making this diagnosis. But, thankfully, lately it has been more widely realized that such findings are only a single piece of the puzzle. They don't rule anything in or anything out; other than that the retina sustained a significant injury. It is not our job as eye doctors to make conjectures in these cases as to what happened.

But when we do see it, it's sad nonetheless. Any more, by the time we are getting called to do the exam, a pretty extensive history has already been undertaken and there is something there that made somebody suspect abuse. This, more than anything else, is probably most useful information that can be gathered. Interacting with parents or the accused during the process is extremely uncomfortable. We walk in the room and there is usually one of two responses.

The first is the catatonic response. The parent that doesn't want to interact much with me, or even the child. Are they guilty or simply in shock at the accusations? The second is the "Oh my God, what do you see, is he gonna be all right?" parent. These are hard to interact with simply because I don't know how much to divulge or to whom. That's when I become the catatonic one.

Just save it. Don't do it in the first place.

The Role of Teaching

As we each progress through residency we learn a large amount of material. I remember as a fourth year student I was quite amazed at just how much stuff there was to learn about two little eye balls and their surrounding milieu of tissues. As I have slowly picked up some of these things, and some of them have actually stuck, I now find myself with a unique responsibility.

Now in my second year, there are three residents now affectionately called "the first years." Although, one of them is a prior trained ophthalmologist from another country. So the likelihood that I could possibly impart anything other than knowledge of how to navigate the local university system is low - I may go to her for ophthalmology questions. As for the other two, I was very recently in their shoes, and I remember well what it was like to know little. Now in my current shoes, and for any other no longer first year, the task of helping to teach the new people is upon me.


This has only reaffirmed, I think, that I want to be involved in an academic setting when I finally grow up. I rather enjoy teaching most days.

Everything Becomes Relatable to Cataract Surgery

I briefly mentioned recently how cataract surgery serves as the bread and butter foundation for eye surgeons. We no longer do it like the guy in the red over there. The steps are much more humane now and the results much more satisfactory.

As I am learning to do cataract surgery, weekly refining different steps along the way, I have noticed something funny. Not uncommonly I will think of some very every day things in a new light - as how they compare to something done during routine cataract surgery. Brushing my teeth is like polishing the capsule - gentle but brisk. Routing the kitchen's trim is like grooving through a nucleus - shave it away until the desired shape is reached. Opening what should be an unopened envelope is like making a good capsulorhexis - don't let any tears go astray.

Making your wife mad is like having a case go poorly - you don't want to have to face up later.

ReReading

A good residency program comes with at least a decent didactics program. I interviewed at several programs where there was no organized lecture time and it's hard to imagine how any accountability is given to the residents. At any rate, we have a very organized schedule. Of course, recent studies suggest it works only moderately well.

Our lecture series, and the board exam as it were, is based on a set of books published by the American Academy of Ophthalmology; all in all a few thousand pages of stuff. We read through the entire series each new year. So, all that said, this being the second year of residency, I am going through the entire set of books a second time. At first I thought this would make the reading easier to sit through. Easier to stay awake during.

It's not panning out so far.

The Maiden Cataract Extraction

One of the rights of passage for an ophthalmology resident is cataract surgery, kind of like for otolaryngologists it's the ear tubes, for the general surgeons the appendectomies, and for the urologists the cystoscopes. One could argue it is much more technical that many of the other surgeries we do, but nonetheless, we start early with them.

The whole surgery is a conglomeration of small steps, none of which individually take very long, which together accomplish the removal of a cataract and placement of an artificial lens. Some of these steps are easy to learn and others take time and time again to get them halfway correct.

But the very first one, the one in which anything can go wrong, is one to sweat and clench through. A good cataract surgeon can enter the eye with the first step and be done in 10-15 minutes. A maiden case takes often an hour, or more. Thankfully, mine went well, and they have done so since then. And patients frequently don't care if it takes so long - they can almost all see better afterwards and are incredibly grateful. Kids are less so after ear tubes - they don't typically know the difference.

Oh That Propofol

The first part of our routine cataract surgeries at the VA involves giving a retrobulbar injection of local anesthetic. As expected, not too many people are very fond of witnessing a long needle coming towards their eye. Really, they wouldn't even need to look at it, but I'm sure it doesn't feel good either.

At any rate, the way we deal with this is to put the patient to sleep for a few short minutes while we do it. One of the best IV medications for the job is propofol - a fast acting, though short-lived injectible. The effects on the patient are nothing short of often comical. You can imagine trying to talk to someone right as they're falling asleep - s/he won't fully comprehend the question, nor even the answery s/he is trying to give. Of course, this is how we know the near full effect is achieved - we ask them questions. When the answers become garbled, quite frequently coupled with big, fat yawns, it's time to inject.

To make the experience more humorous for us (okay, not really, it's for the patient to look at), there's a large paper butterfly taped to the ceiling above the patient's head. So not uncommonly, their final words may be:

"Gargle mmsnuff sshbipner. . .buttterrrfflyyyy. . . ." Nothing like starting eye surgery with a giggle.

The Ophthalmic Hazards of Dentistry

I recently had a patient come into the clinic after what was apparently an eventful dentist appointment. While sitting in the grand chair of dentistry, he had his mouth wide open. The possible implications of this are many, but suffice it to say, we all generally have our mouths open while in the chair of dentistry. He was having some drill work done in his mouth when suddenly he felt as if there was something in his eye. Naturally it didn't want to come out and it is unlikely the dentist looked for it.

So he comes to the eye clinic with this complaint (BLOG!!, I thought). After a thorough exam of the redundant forniceal tissue, I found this little dark chunk. Was it enamel? Was it a chip off the old drill bit? Was a lasting memory of last week's polenta lasagna? Well, I didn't send it for further analysis.

At the end of the day, we all learned one more task during which to wear protective eye wear: being a dentist's patient.

Whether to Publish

One way to beef up an application for fellowship big time is to have publications on board. But not just any - specialty-relevant publications would be nice. I have one online journal publication (ophthalmology based) and one peer reviewed article published on which I am a secondary author (not ophthalmology based). Where does this leave me? Fairly deep in the ground.

I have this research project on which I spent several hours gathering and manipulating data. Then several hours more building a presentation around it. The big question for me lately has been whether to take all of this to publication. The "information" I found was not ground breaking or likely to change the way in which anyone practices medicine. It mere takes something which has not been extensively studied in the past and fails to come up with a concrete answer to anything - just recommendations. And while they may be reasonable or even correct, they aren't deeply grounded. I just don't know that anyone would publish the rubbish.

Then there are a couple case reports I have sitting around I would work on. But even those are getting harder to publish it seems.

A Piece of History

Recap from yesterday: I collect old medical stuff. So I guess in a way this is a continuation of yesterday.

This little (heavy-ass solid cast-freakin'-iron) thing is called an ophthalmometer. I can't say it's something I've ever seen used, nor had I ever seen one prior to acquiring this as a birthday present from my parents. I am somewhat familiar with its close relative, a keratometer. A keratometer is used to measure the curvature of the cornea. This does very much the same thing, though differently. And as a young eye doctor, I have no idea how.

One thing I've been trying to do is figure out when it was made. There are some models out there quite a bit older that this. And those that are much newer are all electronic. All of the mounted manual ones in clinic are also newer, but again, are known as keratometers.

I've got some research to do on this one. But I don't think it will be publishable.

What People Used to Think

For those of you who may not be aware, I am a collector of old medical texts and equipment. This little gem you see here has brought me some real joy by looking at it from time to time. It was written circa 1900 (title pages didn't seem to be a requirement back then) by a very cocky, self-proclaimed expert.

I don't say this because of the statements made about treatments for ocular conditions - things were definitely very different then. He refers to cataract surgery as very barbaric, and back then, it certainly was. It was a big surgery full of complications only to leave you needing coke bottle glasses. But there are many other things stated in this book which are absolutely ridiculous. He has ascribed a "Mild Medicine Method" to all illnesses of the eye and ear. Phsssh. Taken from the text:

"There is barely a hint of agreement, among medical authorities, as to the cause of cataract, but it is pretty generally recognized that among the common causes are overworking and straining the eyes, reading or doing needle and fancy work with insufficient light, injuring the eyes by a blow or by a pressure or rubbing with the hands."  Um, what???

On astigmatism, "For it is not a thing to be cured by the mere use of glasses. It may lead to a permanent injury of the sight, to cataract, or other dangerous afflictions of the eye." I think even most (real) eye doctors then didn't feel this way.

And the best part:
"If your eyes are tired, or if they ache and smart on account of their intemperate use, you should write to or personally consult me. I will give you advice and treatment that will undo the evil you have caused through your own carelessness and neglect. In the schools the sight of hundreds of children is impaired every year by the over-use of the eyes. Teachers should be very careful in this matter. Children had better devote a little less time to the books and preserve their eyes for use in the after life than to have them fail just enough to lead their parents to rush off to an ignorant oculist who may finish the work of destruction already begun." Where was this guy when I was in school?

Of course he finishes the book by telling you how to get to his office and why he was so damn brilliant in placing his office in Kansas City.

What's More Important - Your Kindle, or Your Eye?

So we have had this wonderful patient at JEI who developed a corneal ulcer which ultimately bought her very frequent visits at the clinic. They always do. She was always very religious about making it to her appointments and always did what we asked. It's not an easy course if you've never done it - drops every 30 to 60 minutes in the beginning, sometimes even throughout the night the first few days. That's worse than having a hungry midnight infant.

She always had one thing to talk about which, to her, seemed far more interesting and important than her eye. It was her Kindle. Or her Cruz. Or whatever her most recent e-reader purchase was. She would buy one, take it for a spin (or a read), decide she didn't like it, and then turn around and sell it on Ebay for a profit. And they sold - every time. This lady made a profit turning over e-readers. What was even better was her ever longing desire to show me her latest one. I think it was only becuase I showed an interest.

It was only polite.

The Starving Artist

It's comical to me (so I crack myself up, what of it?) that I often say my patients in the ER, as I'm sewing their face back up, that I compare myself to a starving artist. Okay - so the comparison is weak. But simply draw the thin line between an artist not making any money but trying with his artwork to an underpaid resident trying to delicately put a face together.

The big abdominal surgeon doesn't really care (nor should he) about the resultant belly wound after a big aneurysm repair. The patient could go about his life with only those very close to him knowing of the scar. The case is quiet different when someone has a big laceration on their face. There's this expectation, if not a defined duty, to fix the wound such that any scarring is minimized. It truly can be an art sometimes.

Fortunately, the face tends to heal quite well - especially when talking about around the eyes.

Projectile On Exam

I mentioned once before the difficulty of trying to examine someone when they keep wanting to vomit. But every time in the past there was fair warning; a "Whoa, I really don't feel well." has generally sufficed. Things got just a little too close recently.

I went in to see a patient with orbital fractures who had just been brought up from the emergency room. I'm sure by that point he had been pumped full of IV morphine on an empty stomach. I had done the first part of the eye exam some time ago while he was still in the ER and had only to wait for him to dilate. The story at this point is not embellished in any way. He was lying in bed and seemed quiet and perfectly content; that is not to say there was a smile on his face or anything. I had my fancy light strapped to my head and my fancy lens in my hand. I was leaning in, though not for a kiss, when he suddenly sat bolt upright in bed and spewed across the room. My hand was inches away. Inches.

Fair warning is nice.

The Roast

No - THAT'S a roast.

It has been tradition in our program to roast the outgoing residents on the infamous Resident's Day. It's funny - you spend all day "honoring" the chief residents only to end it by making fun of them. 

There are all kinds of levels, bad to excellent, in which a particular roast may fall. I had see one of the bad types when I was a student - I basically spent the whole time wondering what exactly was going on. At first I thought it may have something to do with the fact I wasn't that close to the resident being roasted. But I later found out that, no, it was in fact just bad.

This past year, I can honestly say they were all pretty good (and not just because some of the roasters/roastees are occasional readers.) Things were tasteful yet still humorous. It can be easy to go overboard, beat a dead horse, or repeat things which have been overdone in the past.

I have since then been wondering how things will go when I do it. I think I have a fairly good idea who I will be roasting. I also think I have a fairly good sense of humor. Only problem is, it is a bit dry for a lot of people. I've been known to be pretty sarcastic yet overly blunt. Sadly, I have already been trying to keep a log of things potentially worthy of a roast.

We'll see.

No - I can't Accept That

It is very common place, particularly at a tertiary referral center like UAMS, to get patients transferred to us who are in need of more specialized care than can be provided at their current location. In ophthalmology, for the most part, this occurs on an outpatient basis. But there a couple examples of people trying to send patients to the inpatient ophthalmology service (what??!?!?) in need of better eye care. (Hey, in our defense, we do occasionally have our own inpatients.)

One patient was one with sudden decrease in vision in one eye, not to mention multiple other systemic vascular issues going on. We don't even admit those people unless IV steroids are warranted.

Another was a surgical patient who complained of blurry vision. This patient had multiple surgical issues going on (as in not having healed from the surgery and now with infection). Would we please accept the patient? Um, no. Try the surgery service for a surgical patient and we would be glad to consult.

What are we, doctors?

It Can be Hard to Go Back to Routine

Old picture, but she still pulls it off much better than I.

For about eleven months of the year, we have morning lectures on Monday, Wednesday, and Friday. Between the time of the OKAP exam and resident's day, the whole morning conference thing went to the wayside.

Naturally we've been back at if for about a month now. Probably one of the more difficult things to do was to get back in the routine of keeping up with a defined study schedule. I have always really enjoyed the fact that our didactic component of the program is rigidly organized - it forces our hand to keep up with reading regularly; whereas in other programs this may not be present and reading is just supposed to happen during  magical free time. I was once told by a smart man that while surgeons may work at the hospital 80 hours a week and we maybe 50, we make up for that other 30 with extra reading. I'm not sure I get in 30 hours a week of reading, but you get the point.

Anyways, I suppose I should get back to reading about the biochemical oddities of the human lens.

Check a Blood Pressure Sometimes

Even an eye doctor can use this.

I have mentioned before the feast or famine nature of the Children's emergency room - I'm either told way less than the actual truth, or the picture is painted way out of proportion. I'm used to it. But what is even worse is when I am consulted to see a patient with an "eye" problem when there is clearly something else going on. This has happened a couple times in the last couple months - and both times at the VA.

The first was a patient who had an episode of decreased vision in his only good eye, the other being nearly lost secondary to glaucoma. So surely I would want to see the patient right away, right? I walk in the patient's room in the ED to find him attached to a blood pressure cuff with fluids running into him. This was his second liter of fluids, with a systolic blood pressure still barely over one hundred. I already knew the problem - hadn't even stated my name yet or seen an eyeball. After further (proper) questioning of the patient, I come to find out he hadn't been eating or drinking, while on diuretics, and had this episode of decreased vision after he stood up and got dizzy and subsequently fell. Most non-physicians could diagnose this - LOW BLOOD PRESSURE. EYE = FINE.

The second was a patient sent from the vascular surgery clinic because he was having intermittent, brief episodes of dimming of his vision. Medications? Oh yeah, he was recently switched from one beta blocker to another because of excessively low blood pressure. What he was not counseled well on was to actually stop the first. So he went home from the hospital taking both. And his symptoms usually occurred while he was standing on a ladder painting the ceiling. Clearly another case of hypotension-induced vision change. Again, LOW BLOOD PRESSURE. EYE = FINE.

Moral? Check some vitals, ask some good questions, be a doctor, and then consult. Only then. These are two gleaming examples of textbook, board-worthy, EASY scenarios.

I Won't Miss the Consults



Not really.

Tomorrow marks the end of the new first years' orientation stretch. This means a few things - all of which are generally good.

First, at least at JEI and the VA, I will never again be responsible for the consults. For the most part. There will always be vacations to cover, but those only come a week at a time. And of course at Children's the consults are done by both the junior and senior resident on a day-to-day basis, but oh well. I can't even begin to tell you how glad I am to be rid of the JEI/UAMS consults.

Second, their help will be present in the clinic. Lightened clinic or not, the extra hand is ALWAYS appreciated, no matter how many or few patients that one person can see in course of a clinic. I remember being in that position and feeling like I didn't contribute much by seeing a small handful of patients,  but I later realized the luxury of (almost) anyone's presence.

Third, they are two weeks closer to taking call which only means less call for the rest of the junior residents. Yay.

"What? Candidemia? Call someone else! . . . .Please."

Ahh Yes, That Was a VA Monday

Everybody likes to tell you about what makes their Monday worse than yours. Maybe it is. Maybe it isn't. Either way, most people have a Monday that sucks for them. For the last eight months, Monday was just another day of the week - busy but manageable.

But now that I'm back at the VA, Mondays are different. I can't really say that I almost forgot what they were like - nobody does. Mornings can be shaky - full AM clinics with a large uncertainty of what level of help will be available. Afternoons are always shaky. There is an overabundance of retinal patients scheduled, and again, uncertainty of what level of help will be available. The retina attending is excellent with his patients and has an excellent bed(chair)side manner. But this comes at a sacrifice for efficiency. Now some people are able to do both, but that can be difficult in a retina clinic. The unfortunate thing is, as a resident clinic, it should be residents doing the lasers and the injections - that's our time to learn them. But instead, to extend more good manner, the attending has a tendency to do them. This takes him away from staffing patients while everyone waits in the hall for him. I myself am not too worried about it since I plan on doing plastics and retinal lasers will be far out of my league.

But as I have said before, the chances are low. So I have to be prepared to do other things.

Awkward Moments

This is another trip down memory lane type of post, but couldn't call it that for duplication of a prior title.

Every medical student goes though four years of school (or I suppose more in some less fortunate cases), and in probably every case, there is at least one encounter with an attending that makes you uncomfortable at least once. The biggest one for me was as a third year medical student.

I was rotating on the surgery service. As part of the deal, we had to spend a couple afternoons in the breast oncology clinic. This was a surgery rotation, and a surgery clinic, so naturally these patients had or were going to have surgery. For those of you who haven't figured it out yet, those shiny, white things in the corner are breast implants. At any rate, one of the attending surgeons who will remain nameless was very eccentric and somewhat odd overall. On a Stamp Out Smoking day she walked around with a fake cigarette in her mouth. Twisted, no?

Apparently at some point she saw an opportunity to make a medical student uncomfortable. Me. She came out of a patient room and practically demanded I come into this room with her. I went into the room and find sitting right there a bare chested woman. I think she even had a bit of a mock grin on her face, knowing what was about to happen. Behind her I swear there was a gathered crowd for the show: a fellow, maybe a resident, a family member or two, and there may have been a clown.

"What do you notice about these breasts?" the surgeon said.
"Well, uh, I. . ." I stammered. Usually there is a rapport established with a patient before you see her breasts. Usually.
"Well go ahead, touch 'em," the surgeon said.
So I did. What else would I do? Firm yet soft, well rounded. "Okay."
"Well, what do you notice about them?"
"I. . .I don't know. They feel different, but okay."
"They're fake!" I think at this point party streamers and confetti flew across the back of the room.
"Oh. Well good job, doctor." Then I turned and left.

Nothing like a wacky attending paired with a woman who is ready and willing.

I Would Be Catatonic Too

As you well know, pretty much every hospital room comes with a TV, and most with a full range of basic cable channels. In fact, at the children's hospital, there is a full X-box set up in most of the rooms, making it difficult to convince them sometimes that it is time to go home.

At the VA, it seems as though the televisions are mostly controlled by a central output. I remember making medicine rounds (now over a year ago!!) at the VA and catching time lapsed segments of the same news broadcast (or Lawrence Welk rerun) as I went from room to room. By the way, as I'm writing this, beer and Starbursts don't go well together, but I keep it up anyway. At UAMS in any patient room that is intensive care or otherwise empty, there is some nature scene with serenading elevator music playing.

But one time, there was something else. I walked into this man's room in the ICU. He was getting frequent followup eye exams by us for something in his orbit. As I walked in, I found on the TV an invigorating episode of Curious George. He was, of course, just staring blankly at the screen.

I think I would also remain catatonic if someone left that on TV for me. I just hope it wasn't on a loop.

The Excitement of the New Guy

You know I'm interested in doing a fellowship in oculoplastics. You know how much it would mean to me to gain a spot in such a fellowship. So naturally when I found out we were looking for a new oculoplastics physician, I was intrigued. Then, I found out we had actually hired one (tough to do on the tight JEI budget). Then I was truly excited.

After his arrival I found out what true excitement is. He is a young guy, fresh out of fellowship and after a stint in the military. He is far more published that most people this early in his career. His sheer enthusiasm for doing more research is nearly infectious.

We have a couple more new folks starting the coming months, but I somehow doubt they will match his excitement at being where he is.