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.

You Know You're Ready to Rotate When. . .

This may be a bit dated since it applies more to when I was nearing the end of my UAMS rotation, but I feel it will soon apply again since we are now on two-month rotations instead of four.

Because of the way things are, I spent eight straight months at Jones Eye Institute. I like most of the people there, enjoyed the relative ease over there, but was more than ready to leave. There are certain telltale signs to prove ones readiness.

One of these is counting down to the end of a rotation by the number of clinics. For example, at one point, I know I was saying, "Only three more Friday afternoon clinics until I leave this place," or, "Only two more neuro-op clinics left this block." It seems small to you, but these are milestones. Yeah, yeah, Mia sat up at six months, and that too is a milestone. But she never had to sit though contact lens clinic, she never had to sit through Friday afternoon optics lectures.

I know, I know. Big baby. Still, all countdowns come to an end. And I was happy.

An Update From the Fourth

From Happy Bear Fireworks

The Fourth of July is an ophthalmologist's worst nightmare. That and New Year's Day. These are the two times a year when people can legally shoot fireworks, so naturally the do. Hey, we did too, but more on that later.

We at UAMS hate it even more because that is when the community ophthalmologists disappear (smart) for the weekend and their respective community hospitals are left with no coverage. As we start to roll into the weekend, so do the injuries.

As a general rule, injuries are secondary to things like bottle rockets and roman candles causing blunt trauma to the eye, resulting in a hyphema, or bleeding in the eye. But sometimes, the larger fireworks unexpectedly explode before people have a chance to get back. This has happened. And in one case, the eye injury was significant enough that the eye had to be taken out.

So we did fountains, sparklers, and smoke balls, but overall nothing projectile. I leave that for others, and watch from a distance.

Back At The VA

I may have ended the first year yesterday, but with the beginning of the second today, I have returned to the VA. There isn't a busier rotation.

It will have its upsides, though. During this block I will start operating on a regular basis. I will be starting with cataract surgery, though at the children's hospital others will be starting with different things. Don't get me wrong, there are cataract surgeries done on children on a regular basis; but, the residents don't generally do much of them.

We'll see how things go. Currently my first cataract case is on Thursday next week. It would have been Tuesday, but that one already cancelled. Don't even get me started on what will be that huge headache. There are a lot of ways to cancel a cataract surgery, particularly at the VA it seems. And anesthesiology folks are often the driving force behind them (though not in this particular case). It's almost as though they just don't want to have to sit around during our cataract surgeries. Why not? They require minimal effort by anesthesia at the start of the case; the rest of their time is spent on an iPhone or with a magazine. Not being mean here, just simply stating a fact. The job doesn't get much easier than being in a cataract case.

Anyway, I have bid farewell to eight straight months at JEI. And not that there was any one person to blame, but that was just too much.

Goodbye to First Year. . .Again

I will take this opportunity today to stand for what I have gone through as a first-year resident. Again.

See, some specialty residencies have a unique start to them in that there is an initial transitional or intern year which may have little to no exposure to their specialty of choice. At UAMS, this is primarily the ophthalmology and dermatology residents. Many of the surgical subspecialists (though, dermatology is not a surgical specialty) have several months of general surgery scut or other "off-service" months, but they still get several months of their desired specialty. We got one month of ophthalmology, and it was one during which we just followed someone around and weren't allowed to do much. The other eleven were all internal medicine without even a once-monthly eye clinic to attend.

So then my actual first year of ophthalmology came around. I was finally really getting used to being a medicine resident when my feet were lifted off the ground and I was pushed over without a solid surface on which to stand. Even though I was a PGY-2, I knew nothing. I was like an intern all over again.

Alas, as a PGY-3, I have surpassed that point. I know a thing or two. And for once, I can spend the next year expanding on it. I can honestly say, "Okay, I've done this. I've seen this. Now what more do I need to learn about it?" Obviously, the answer will always be, "Plenty."

Sample Medications

It's hard in this age of medicine to know what to do about free samples of medications.

There was once a day when wherever you went you were able to get free samples of the newest medications on the market, and nobody had a real problem with it. Ophthalmologists were certainly no exception to this with entire cabinets full of eye drop samples.

But things have changed. The great exposure of the pharmaceutical industry led many to become more aware of the problems with free samples. Free samples were equated with getting a patient on a branded, new medication for which they would in the future require a prescription and pay a lot of money. Most university health care settings have essentially banned the presence of pharmaceutical representatives from their campuses. Most would agree that this is generally a good thing. But have they really gained anything with the banning? If you figure that most of these patients are uninsured or have at best Medicaid/Medicare, which frequently won't cover the cost of the newer, higher priced medications, then the university wasn't a huge motivation for sales people.

Still, there is another side to it. Essentially all new drugs in their infancy are only available as the expensive brand name due to patents. And sometimes, just sometimes, the new medications is in fact the next best greatest thing.  Unless an unbiased overwhelming amount of literature and data suggest otherwise, I typically don't prescribe these drugs until they've been on the market a few years when more safety data is available. But, again, sometimes the new drug is just too good to not use. And considering many of my patients would never be able to afford such a thing, is it so wrong to continuously give them free samples? You may argue that as long as the company is giving out free samples, the cost of the medication will remain high or even rise. This, I don't think, would hold water when you figure that the overwhelming majority of the company's income goes to profit and advertisement (which they often include in their supposed "R&D" costs), not manufacturing costs. There's good literature on this out there - I recommend you read it.

So I still believe that in moderation, the dispensing of free samples can be helpful to good patient care. So long as there aren't associated kickbacks, awards, and presribers' interests at hand. Now if you want to talk about equipment and instrument representatives, that's an entirely different story.

Our Company Stole My Pain Meds

Working in a university setting we get a lot of patients who are uninsured and also frequently drug seekers. I'm not stereotyping here, but the two characteristics often occur together.

At any rate, the range of excuses used to explain how a 30-day supply of narcotics disappeared in seven days is quite broad. But this one certainly stood out the other day. In the post-operative period for eye surgery, we really don't even give out much pain medications. There are only a few surgeries which warrant good pain medications, and an open globe is one of them. One of these patients walked into the clinic, appearing to be perfectly well (aside from the obvious eye injury status post repair) and not in any pain at all. In the clinic room, it was a parent (not even then twenty-year-old patient) who first brought up the recent loss of pain medications.

It wasn't the typical "Oh, I've been in so much pain I've taken it already," or the, "No, doctor, I wasn't given the prescription when I left the recovery room." It was, "We had some company the other night who stole the pain medication."
"Well," I said to the patient, "you look to be doing well anyway."
"Oh, no, she's in a lot of pain," says Mom.
"I wasn't talking to you." I turn back to the patient.
"Oh, yes, I'm in too much pain," the patient said with the flattest face ever.

I couldn't help but give her two more days of pain medications and then refuse to see her on the return visit - she (her mom) would be someone else's problem.

Don't Play With Your Food

Pear

Whenever someone gets hit hard enough in the eye, though not hard enough to rupture it, it is very common to suffer what is called a hyphema. This is when there is bleeding in the eye, though in front of the iris. This turns out to be something that is heavily dreaded during the fourth of July season.

Hyphema

But recently, I encountered a type of injury a little unusual to me. A couple of kids were playing around some pear trees. Turns out a couple of them were decent baseball players. They got to throwing the fruits around and, as anticipated by the direction we're going, one of them took one to the eye and got a hyphema from it. I hope it was at least a pitcher-type that threw the darn thing.

When this happened, I immediately thought of, "Honestly, who throws a shoe?

Austin Powers