Tuesday, June 12, 2007

A Funny Story During My Surgery Clerkship Rotation

Funny story I heard from a friend about a med student and the Chair of the Surgery Department here... we'll call him Dr. B

The student (let's call her Amy) is a 4th year med student rotating with Dr. B for a month on the general surgery service. Dr. B is known for being very touchy-feely with his patients and listening to their issues.. you know, the "softer" side of medicine. However, he's still a surgeon and definitely has a serious side.

The patient they are about to see on morning rounds has had many problems during her life. In addition to her surgery, she has many co-morbidities as well as stresses in her life. She has also been battling depression and weight issues. Today, her main concern is some kind of eye problem. Maybe a corneal abrasion or conjunctivitis, who knows. Dr. B and Amy proceed to talk to the patient and then perform a physical examination. Both carefully inspect the patient's eyes, conclude their visit, and quietly leave the room to discuss:

Dr. B: So, what did you think?
Amy: She has a lot going on...
Dr. B: I mean, what did you see in the patient's eyes?
Amy: Umm... sadness?

Dr. B: ...
Dr. B: What?! Go look in the patient's eyes again! What did you see IN the patient's eyes?!

Oh, Amy, sometimes you just can't win for trying =)

Rev 20200228

Friday, June 08, 2007

My Surgery Core Clerkship Experience

Surgery has been going pretty well. I only have 6 more days of general surgery! The time has really flown by. In the few weeks I've been here, I've seen several excisional breast biopsies, some laparoscopic Roux-en-Y gastric bypasses, some Port-A-Cath insertions/removals, a laparoscopic gastric banding procedure, and laparoscopic cholecystectomy. Not the broadest variety, I know, but it was good to see the same thing done several times to see the variety / scope of the technique. I also have gotten better at suturing up wounds and feel much more confident about my manual dexterity before starting surgery. It really is like tying knots on your shoelaces... slippery, bloody knots, but still.... same idea =) What I really should be doing is studying for the surgery shelf exam!

Some drink for thought: Does a "break the seal" phenomenon truly exist? I had never heard this phrase before, but OverMyMedBody has an interesting post about whether the first bathroom episode after drinking leads to subsequent ones.

Updated 20200228

Sunday, June 03, 2007

Tips On Scrubbing In

Note: if you arrived on this page looking for more information on nursing programs, please check out: Nursing Degree Programs

As the name of this blog implies, I should probably offer some advice on how to scrub in, especially since I am on my surgery rotation right now. So, here is some help for all of you out there for whom "sterility" still means that you can't make babies =P

So here goes. Scrubbing in is actually pretty easy, but it can be confusing the first few times. The following pointers are roughly in order of how one scrubs in to an OR.
  • First, as you enter the area where the OR suites are, put on a surgical cap and face mask. I'll assume that you are already wearing scrubs. Supposedly, the 'bath cap/cafeteria lady' caps are more sterile, but... well, the caps just look better. As I later learned, the poofy caps are called bouffant caps.
  • Find out which OR you are supposed to be in. Most hospitals have a whiteboard somewhere outside the OR suites that lists the cases and attending surgeons.
  • After you find the OR, enter it and find the nurses. There are generally two nurses: a scrub nurse who has already scrubbed in and will be assisting with the procedure, and a circulating nurse who is NOT scrubbed in and will take care of prepping the patient and bringing any supplies that are needed during the procedure. Introduce yourself to them as a medical student, and offer to get gloves and a gown for yourself (usually either on a shelf in the room, or in a supply room adjacent to the OR).
  • What glove size should you get? Well, the average male hand is generally about a 7.5. The gloves should fit snuggly, but not to tightly. You want them to protect your fingers from needlesticks, but not so tight that they would tear easily.
  • It is recommended that you double-glove when you start off to provide more protection. If so, you should always put the larger pair of gloves on FIRST (e.g., if you are a 7, put on a pair of 7.5s first, then the 7s). Double gloving increases safety but decreases dexterity and touch sensitivity.
  • When you bring your supplies back, you need to hand them to the scrub nurse in a sterile fashion. To do so, open the packages partially so that the contents inside stick out. This will let the scrub nurse grab them without making contact with you or the external part of the package. If the gown is wrapped like a gift, hold it firmly by one edge, then pull the corners apart one by one, and tuck them underneath. Imagine it was a sandwich with a wrapper on, and the gown is the sandwich: you want your hand on the wrapper to keep the "sandwich"/gown clean, but you want the "sandwich"/gown exposed to the scrub nurse so that they can grab it.
  • Now, help the circulating nurse prep the patient. Once this is done, you can go outside and scrub in. This is where you do the actual "scrubbing." There are many ways to do this, but here is one general approach. Find a sponge with soap on it (usually right above the sink). Open it, and wet it on your hands. Now, scrub each surface of each finger on both hands for several seconds. Then, do the palm and dorsum of each hand. Then do your forearms. How long do you scrub for? The best response I have heard is, longer than your attending/residents if you start scrubbing at the same time.
  • After scrubbing, make sure to rinse by moving your arms under the water in only one direction. Get all the soap off. Now, do NOT dry off with anything around the sink. Let the water drip down your arms towards your elbows and away from your fingertips. Proceed into the OR and find the scrub nurse. They will hand you a sterile towel to dry off with. Keep your arms between your nipples and navel at all times.
  • To dry off, again start at your fingertips and work your way down. Make sure your fingers are VERY dry, as wet fingers are hard to get gloves onto. Do one arm entirely, then flip the towel so that the now-clean arm is touching a dry part, and proceed to clean the other arm.
  • Once dry, dispose of the towel and approach the scrub nurse for your gown. To put the gown on, just put your arms through and reach for the sky (but make sure there's nothing overhead). Put your arms through so all your fingers barely poke through the cuffs. The circulating nurse will button/tie up the back.
  • When the scrub nurse offers you a glove, simply shove your hand downward. Do not worry about getting all the fingers on properly, as you can adjust this later once you have your other glove on. Repeat this for the other hand. For the second glove, you can help with your gloved hand by pulling the second glove open more.
  • Once both gloves are on, you can adjust the fingers appropriately. 
  • Now, to tie the scrub on, hold on to the short strand and tear it (and only it) from the card. Hand the card to the circulating nurse, and turn around. Now, grab the second strand so that you have both strands, one in each hand. The nurse will tear and dispose of the card. Tie the two strands in a knot.
That's it! You're scrubbed in now! Enjoy the procedure =)

Not scrubbed in but still in the OR? Want something to study while your avoid eye contact with the attending? Check out:

While not a primary resource for your surgery shelf, Surgical Recall is great for those random 5 to 10 minute breaks you get during the day on your surgery rotation. Crack open the chapter relevant to your next case, read up, and look like a star when you're pimped on rounds. And yes, it truly does fit into your white coat's pocket!

Updated 20200228

Saturday, June 02, 2007

Tiii-i-ime, It's on your side...

Ever stress about how much time you're "wasting" instead of studying during med school? Eh, don't sweat it. Read this instead! =)

May 31, 2007
Life’s Work

Time Wasted? Perhaps It’s Well Spent

WASTING time gets a bad rap. We pester our children not to do it; we take pride in the multitasking that ensures we never do it; and we bristle at our fellow workers, shop clerks and just about anyone else who slows us down by doing it.

But we all do it.

One of my favorite books as a child was “Cheaper by the Dozen,” the story of Frank B. Gilbreth Jr., who introduced the idea of efficiency to 20th-century America. His time-shaving techniques ran the gamut from a new way of laying bricks to a quicker method of buttoning his vest (bottom to top, saving four seconds).

Inspired, I slept in my clothes for a few nights back then to save time dressing for school, though I don’t think that’s exactly what the man had in mind.

I can only imagine what Mr. Gilbreth would have made of the modern workplace, with its endless possibilities for distraction. His 21st-century counterparts are an army of product researchers, academics and personal improvement gurus, who all agree we are frittering valuable minutes, hours and even entire days, though they can’t agree on how many.

American workers, on average, spend 45 hours a week at work, but describe 16 of those hours as “unproductive,” according to a study by Microsoft. America Online and Salary.com, in turn, determined that workers actually work a total of three days a week, wasting the other two. And Steve Pavlina, whose Web site (stevepavlina.com) describes him as a “personal development expert” and who keeps incremental logs of how he spends each working day, urging others to do the same, finds that we actually work only about 1.5 hours a day. “The average full-time worker doesn’t even start doing real work until 11:00 a.m.,” he writes, “and begins to wind down around 3:30 p.m.”

The experts disagree on how we are wasting all this time. The AOL survey says time is lost to surfing the Internet (given the source, that is either self-congratulatory or self-incriminating).

The Microsoft survey pointed to worthless meetings. Respondents said they spent 5.6 hours each week in meetings and 71 percent of them thought that those meetings “aren’t productive.”

Searching through clutter is another diversion, says Peggy Duncan, a “personal productivity coach” in Atlanta, who maintains that rifling though messy desks wastes 1.5 hours a day.

But wait, you say, you spend all your time working. Your boss is a slave driver. You’re the only one left in the office after the downsizing, meaning you are doing the work of three people. Well, there are numbers that also support this situation.

The average professional workweek has expanded steadily over the last 10 years, according to the Center for Work Life Policy, and logging 70-plus hours is now the norm at the top. And there are those of us who work even when we are at home, driving or worse. A poll conducted for Staples found that almost half of the small-business managers in the United States work during time meant for family, while 49 percent make business calls and check e-mail messages while behind the wheel; 18 percent read e-mail messages in the bathroom.

So how to reconcile the seemingly conflicting trends — the fact that we are working harder and wasting more time? A crotchety boss might say that we’re working longer because we’re wasting time, but the opposite may also be true. We are wasting time because we are working harder.

“The longer you work, the less efficient you are,” said Bob Kustka, the founder of Fusion Factor, a productivity and time-management consulting firm in Norwell, Mass. He says workers are like athletes in that they are most efficient in concentrated bursts. Elite athletes “play a set of tennis, a down of football or an inning of baseball and have a pause in between,” he says. Working energy, like physical energy, “is best used in spurts where we work hard on a few focused activities and then take a brief respite,” he says.

And those respites look an awful lot like wasting time.

It has taken me years to make tentative peace with my stops and starts during work. Every morning I vow to become a morning person, starting full speed out of the gate. And every morning I daydream, shuffle papers, read e-mail messages and visit blogs, and somehow it is time for lunch. Then, at about 2 p.m., a sense of urgency kicks in, and I write steadily, until about 5 or 6, when I revert to the little-of-this, some-of-that style of the morning.

Over the years I have come to see that the hours away from the writing are the time when the real work gets done. When a paragraph turns itself this way and that in a corner of my brain even while my fingers are buying books on Amazon.com. What appears to be wasted time is really jell time. This redefinition only makes me feel a little less guilty.

Mr. Kustka assures me that the problem is not the three to four hours of concentrated work I do each day, but rather the outmoded paradigm against which I measure that work. Productivity was directly related to time back when Mr. Gilbreth was measuring things, he said, but the connection is less direct today.

“We are in a knowledge-worker world,” he says. “If you were building me a building, I could measure the number of bricks. If you were loading a truck, I could measure the number of boxes. But I can’t simply count your words. That doesn’t measure quality.”

I didn’t have the heart to tell him that word count is how nearly all freelance writers are paid.

Instead I focused on his more general point that it shouldn’t matter whether I wrote these words in hours or days, at a desk or on a deck — the end result is all that counts.

“The old thinking says ‘the longer it takes, the harder you’re working,” says Lynne Lancaster, a founder of BridgeWorks, a business consulting firm. “The new thinking is ‘if I know the job inside and out and I’m done faster than everyone else then why can’t I go home early?’ ”

A few companies are taking the concept of “watch what I produce, not how I produce it” even further. At the headquarters of Best Buy in Minneapolis, for instance, the hot policy of the moment is called ROWE, short for Results Only Work Environment.

There workers can come in at four or leave at noon, or head for the movies in the middle of the day, or not even show up at all. It’s the work that matters, not the method. And, not incidentally, both output and job satisfaction have jumped wherever ROWE is tried.

In other words, what looks like wasting time from where you sit, could be a whirl of creative thought from where I sit. And, with due respect to Mr. Gilbreth, all the energy that’s been poured into trying to force everyone to work at the same pace and in the same way — it seems that’s the real waste of time.

E-mail: belkin@nytimes.com.

Life’s Work, a column about workplace trends and office culture, appears in Thursday Styles every other week.


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