The Inimitable Dr. Poole

Surgery was my last class of the M3 year. The rotation consisted of six weeks on general surgery and three separate two-week subspecialty blocks. There seems to be a little something different about surgery to me that I can’t put my finger on. It has a certain aura about it that is lacking in all of the other clerkships. Maybe it is the rigidness of the OR and all of the sterile scrub techniques you have to deal with. Perhaps it is all the war stories you hear about some of the attending staff. Whatever it is, I did not have the same confidence going into it that I felt about the rest of the year. To make matters worse, I was to begin on General Surgery C. The attending physician for this service has more stories told about him than all of the other surgeons combined. Dr. Galen Poole’s reputation precedes him. There is the story about him hurling the box of instruments against the wall because it was the wrong kit. The forced anger management classes. The tirades in the ER on trauma call about none of the gang-bangers knowing how to shoot straight and just maiming each other instead of killing. I suspected that much of the litany had to be more legend than fact, but I would learn from experience that it was probably all true. I knew I needed to get off to a good start. I read all of the “How To Be A Good Surgery M3” sections of the review books. I got advice from my classmates who took surgery earlier in the year. I was going to be ready to dazzle the great Dr. Poole with my vast knowledge accumulated over 9 months of clerkships. There were two other students with me on Poole’s service and on Sunday evening we got together to go over the patient list and split them up. We were each supposed to see our patients early Monday morning, review their charts, get up to date with their hospital course, write a progress note, and be ready to present them on rounds at 7:30 am.

Unfortunately, my six-year-old, Manning, went into the hospital with pneumonia that weekend. I was spending the nights with him and I figured I could look up labs and radiology reports on the computers at the Children’s Hospital where Manning was. I also hoped maybe to run over to the adult floors and read through the charts to be ready. Because Angie had to get the girls off to school the next morning she wasn’t able to get to the hospital to relieve me very early. I tried to get as much done as possible but it just didn’t work out. By the time 7:30 rolled around I knew enough about my patients to know that I was ill-equipped to answer anything but the most straightforward questions. Like, “What kind of surgery did Mr. Johnson have?” or “Is Smith a man or a woman?” There is a Law of the Third Year of Med School that states that no matter how much time you allocate to researching new patients, it will never be enough. As I went to meet the team for rounds I thought, “well if I can’t dazzle them with my patient knowledge, I can at least be prepared for all of the wound dressing changes and such.” One of the tips for being a good M3 I had read so much about was to always carry a lot of 4 by 4 gauze sponges and tape in your lab coat. When you round, the surgeon always wants to take a look at the wounds (some of them quite nasty) and redress them. He expects the student to whip out the necessary supplies. So I jumped into a supply closet and grabbed a handful of the first packs I saw that had 4″x4″ printed on them. When we started on rounds, some of the other student’s patients came up first. When it was obvious that they too were not yet completely up to speed on their charges, I began to relax a little bit. After all, how could you possibly be expected to know everything about somebody who had been in the hospital for two weeks when it was you first day on the job? This wouldn’t be too bad. In fact I was feeling almost at ease when Poole looked over the perineal wound of a guy who had undergone a complete colonectomy. The rectum and anus had been removed also. The wound had been left open to heal by secondary intention, and when it closed up, the guy would have no hole anymore. A colostomy bag up on his abdomen would be the only outlet for the GI tract. Poole declared it “looking good,” as if any such thing horrific thing could qualify. He repacked it with some of the Kerlix dressing on the nightstand and then turned to me asking for some gauze pads. There it was. The moment to show my preparedness. I yanked a pad out of my white coat pocket and ripped it open to reveal … not a 4″x4″ gauze pad, but a 4″x4″ anti-microbial drain sponge. Poole looked at me in disbelief. How could anybody be so foolish? “That’s a DRAIN SPONGE!” he bellowed. I grabbed the whole stack out of my pocket to see if it was just a wayward drain sponge. Perhaps I still could redeem myself if I could come up with a gauze pad. Before I could further inspect my holdings, Poole went on, “Don’t open any more! They’re all the same thing! That’s how money gets wasted in the hospital!” Hmm. I would have sworn that accidentally opening a drain sponge when you need a gauze pad was not high on the list of cost containment snafus. Thankfully, my fellow student, Janet, turned out to be a much better M3 than I. She gracefully pulled out several gauze pads and when the guy’s significantly modified crack was once again properly dressed, Dr. Poole informed me that it would be my duty each morning to redress it just as he had done. Great. That’s what makes early mornings on surgery so much fun. Getting to the hospital at 5:30 a.m. to repack perineal wounds.

It turned out that I really got to like Dr. Poole. Sure he was volatile. But he was also funny and a good teacher. He kind of reminded me of one of my sports heroes, basketball coaching legend Bob Knight. I have read a couple of biographies on Knight and his teaching techniques and temperament are real similar to Dr. Poole’s. Poole will berate the residents and cut them no slack at all. I think they all start out hating him, but somewhere during the five-year residency they realize that through all of the bluster, he is making them better surgeons. By the time they are senior residents they will do anything for him. And when he writes their evaluations and letters of recommendation, he does so with glowing reviews. Even if he just finished telling them in the OR that they have got to be the WORST surgeon he has ever seen. A lot of it is kind of for show. He can just go off on a resident during a case and belittle their skills in front of everybody in the OR but then will look across the table to the M3 and wink. On the third day of the block he asked me if I was nervous about being on surgery. I knew I couldn’t deny it because it would appear cocky and he would move in for the kill. But letting him smell too much fear would be like tossing blood in front of a shark. I admitted that I was a little apprehensive.

“Why?” he demanded?

I explained that is was probably due to all of the unexpected, the mysteries of the OR, etc.

“You’ve heard that I’m the meanest sonuvabitch in this place, haven’t you?” he asked.

“Well there are stories out there, sir.”

He laughed at my forthrightness and told me to relax, that we were going to have fun. And we did. I am quite sure that surgery is not for me, but I did learn a lot and will always remember some of my experiences in the OR scrubbed in with The General of UMC, Dr. Galen Poole.

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The Code Blue Blues

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My introduction to “running a code” came early on my medicine rotation. At our school, the on-call medicine team is the group to carry the code pagers. When somebody on the floor at the hospital goes into respiratory or cardiac arrest, a “Code Blue” is called. When these special pagers go off, all hell breaks loose. There is a mad tear as residents, nurses, and other staff go flying off to try to bring somebody back from the edge.

My first experience was around dinner time one weeknight. As M3s, my buddy Shane and I were taking orders from our team for supper from a local establishment. While some M3s despise being called to gofer duty and somehow feel like it is an attack on their self worth to be asked to go pickup carryout, I actually like it. I would much rather spend a little time outside of the hospital tooling around town, rather than being in the ER, watching the intern take yet another history and physical from a homeless person with belly pain lasting for two months. Anyway, we were taking orders and collecting money from the senior resident, intern and M4 on our team when the dreaded call came. As I was running down four flights of stairs I realized that it was not a good idea to wear faux Birkenstocks while on call. I managed to get to the patient’s room without rolling an ankle and tried to blend into the huge crowd packed into the small private room.

Everybody on the medicine team has a role to play. The senior resident is the leader and gives direction. Another resident gets the patient intubated and an intern gets a femoral line in. The M4 is first in line to perform chest compressions and the M3s are supposed to standby to relieve him. In this case there were a lot more people involved. An ICU nurse was on the scene and was helping to get the defibrillator patches on. Everything was crazy. Apparently the guy had no pulse but an implanted defibrillator was going off constantly and confusing everybody. Somebody was yelling to get the “crash cart” plugged in because the defibrillator was out of juice. Somebody else realized that there were family members still in the room and a guy who I had never met pointed towards me and hollered, “get them out of here!” I looked around thinking, “Who, me? I’m not qualified. I’m just an M3.” Before I could form my action plan, a nurse tried to pull a couple from behind the door and out into the hallway. They refused, the guy declaring that he would never leave his brother. I kind of stupidly looked up and realized that a syndicated episode of Seinfeld was playing silently on the television mounted over everybody’s head. To my inexperienced eye, it seemed like total chaos. As someone took over on chest compressions, the M4 on our team backed out of the room with Shane and me. He was a whiz kid type. Very smart and impressive. It was hard to believe that he was only one year ahead of us in his training. He looked over the scene glumly and remarked, “I haven’t ever been to a code outside of the unit (ICU) that wasn’t just a cluster f@*#.”

It was looking pretty clear that we were losing and our patient was not coming back. As our senior resident formally called a close to operations, our cool M4 turned to me and pulled a $10 out of his wallet. “I’ll take the chicken strip dinner with fries and a coke.” And with that the guy was declared dead, and the adrenalin rush was over. People began trickling out of the room. The family was escorted to the waiting room to share the bad news with the rest of the clan. The naked dead man on the bed looked violated with the line coming out of his groin and the endotracheal tube jutting from his mouth like some weird pacifier. Because he had a lot of gold jewelry on, Shane and I were given the first job of the night that I felt competent to handle. We were posted out in the hallway with instructions to let no in go in without authorization until the morgue could arrive. We only had to wait a short time before we were released from duty and headed out to pick up supper.

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Spring 2004

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The fog that is the third year of medical school has lifted. I would like to tell you that I have been too busy studying during every spare moment to post diary entries. I would like to tell you that the pursuit of a top spot in my class and a choice residency at Harvard has left me no time to even get on the internet. The truth is that most of the time when I got home from the hospital I was ready to just chill out and not think about any medicine. We finished up our clinical duties on May 28 and then took a week off to study for the shelf board exams. We took those 6 exams in an eight-day span and left the long year behind. Goodbye to the pain and suffering of the M3 and hello to glory days of the M4. It is a cliche in med school that the 4th year is the best year of the rest of your life. Most claim they would do it forever if they could figure out a way to get paid for it. You get to take courses you’re interested in, not much is expected of you, you can do all the procedures that you want, and you are not responsible for much at all. The free time is also very sweet. We have to do 8 one month blocks between July and May of next spring when we graduate. That means 3 whole months completely off. And some of the 8 months are almost like being off. For instance I am taking Computers in Medicine in July. I will have to do a couple of days worth of research on a topic that I am interested in anyway and make up a small presentation. The whole month’s course will maybe take me 4 days of work. So I will try to be better about writing and use some of this free time to look back on the funny and not-so-funny experiences of the third year.

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September 14 2003

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The Blair E. Batson Children’s Hospital has an inscription in the entryway which reads “Children are a message that we send to a time that we will not see.” I liked to read it every morning when I went into the hospital on my Pediatrics rotation. What will the world be like when the kids I saw each day are my age? I saw a lot of kids who didn’t seem to have much potential for messages of hope. Every week at UMC, dozens of infants are born. Too many of them come into the world with two strikes against them before they get our of the newborn nursery. There are crack babies, fetal alcohol syndrome babies, and HIV positive babies. I saw a two-week-old admitted for a femur fracture. She had “fallen” off of her father’s chest while napping, and he “caught her by the leg.” Another newborn had to stay in the hospital for two weeks due to failure to thrive. The mother checked out on the third hospital day, left a number where we could reach her when the baby was ready to come home, and never once came back to see her child. I found myself feeling despair for these kids who would probably never know a stable home, have regular hot meals, somebody to read them stories at night. They were starting life in so deep a hole that most of them would never climb out. Initially I felt resentment and bitterness toward the parents but then realized that most of these teen-aged moms probably started out life in the exact same way 14-20 years ago. If I didn’t expect these babies to have the opportunity to make something of their lives, why would I expect anything different from the prior generation? It really is a vicious cycle. It was really a contrast from the private hospital where Angie gave birth to our four kids. It always seemed like such a happy place. There were wreaths on the doors with blue or pink ribbons. New grandmothers stood by the nursery windows, staring in wonder at their sweet new sources of pride and joy. Dads pulled up to the front doors in SUVs with fancy new car seats to take their precious bundles home. At UMC you have to call in social work to help you find somebody to send the baby home with sometimes. Of course this picture is not the case with all or even most of the babies I saw but it is enough to make you wonder how the future can be bright with so many of its members bound for misery and despair barring some unforeseen intervention in their lives.

The Children’s Hospital is the best of places and the worst of places. There are kids who are so sick that they will never go home and others who will have almost miraculous care and get well. I don’t mean for this entry to be such a downer because overall my six-week peds rotation was a great experience. Most of the time and for most of the kids, it is a place of healing and hope. Having completed my rotation a week ago I can really see myself doing peds. I had a week in the newborn nursery, a week of clinic, and four weeks on the house team, and these last weeks were a lot of fun.

I followed a 7-year-old girl with a disease I had never heard of, dystrophic epidermolysis bullosa. This is a genetic disorder with a faulty gene for collagen VII which causes the skin to blister and slough off. Every tissue with a squamous cell epithelium is effected including the esophagus. This girl is admitted fairly often because of esophageal stricture secondary to her disease. She has lived her whole life on pretty much a liquid diet but sometimes her esophagus will blister and leave her unable to swallow so she needs parenteral nutrition and IV fluids. When I went in to see her on the night of her admission she was sitting up in bed watching a baseball game. Her Dad told me she loved the game and would watch any team that was on TV. Her parents had always sheltered her from playing sports because any kind of trauma can be devastating to her skin, but she talked them into playing softball this summer. The next morning I brought her a box of baseball cards and a card that one of my daughters made for her. When se got ready to go home, she gave me one of her softball pictures and a picture she drew. She was such a sweet and brave little girl.

I also met a little boy who was closer in condition to my son, Manning, than any other kid I have ever met. He had infantile spasms and intractable seizures his whole life. The same surgeon that did Manning’s hemispherectomy had dome a corpus collosotomy on this boy and he had been seizure free for a few months until the week of admission. He was only a year younger than Manning and had many of the same characteristics. He was floppy and weak but had those big eyes that made him look like he was somewhere far away. Maybe a place that is better than here. His mom sat on the bed next to his crib and made him a balloon from a latex glove. She wrote “I love you” on it and I could feel the aching that I get in the back of my throat when I think about my kids and Manning especially. She had adopted him at birth. I felt like I knew what the years had been like for her and how probably most of her friends knew what sacrifices she made but they probably still didn’t know what it was like for her at night as she lay in bed and listened to her little boy seize. For her the Children’s Hospital is a great place. A place where everytime you are admitted, the hope that something good will happen lies just around the corner.

Then there was the 15-year-old girl with Sturge-Weber who just wanted to get back to her high school basketball team. Her friends came to visit on a Friday night to fill her in on all of the school gossip.

There was seven-year-old boy with CF who hadn’t pooped in a week. He wasn’t about to let anybody stick an NG tube down him, but his belly hurt so bad he promised to drink the GoLytely if they just would get that tube away from him. And he did. 2.4 liters worth over 24 hours. When I asked him the next morning how he felt he said ,“Great!” I asked him how many times he went to the bathroom during the night and he told me had lost count. The most important thing was that he was going home and wouldn’t miss the wrestling match at the coliseum that weekend.

The pediatricians are very good to work with from the attendings down to the interns. I met a lot of great doctors and learned a lot. While the attendings are all obviously very smart and serious, they seem like they have fun. The wear Batman logos on their lapels and have ties with smiley faces on them. We had “rounds” one day sitting in the hospital McDonald’s dining room having smoothies and carmel cake. They had a big rotation party for us at a local burger dive. And they all told me what a great job I was doing even when I couldn’t remember what day of Rocephin my patient was on. I am only one week into Medicine but it seems a world away from the Children’s Hospital. I miss it already.

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July 13 2003

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I didn’t realize how anxious I had become about getting my Step 1 score until late Wednesday afternoon when I still had not gotten the promised page from the Office of Student Affairs. We had been given strict instructions to not call in bothering them until we had been paged. Scores come out each Wednesday and most of my class was expecting their result this week. In fact I checked the NBME website early Wednesday morning and learned that my score was indeed being released that day. So I waited and waited and waited but the page never came. Uh oh! That seemed like a bad omen to me. They were probably calling all of the passers first. My mother is in town from New Mexico and was taking the family out for my belated birthday dinner, so I tried to just forget about it and enjoyed a great steak. But by Thursday morning my nerves were on edge again, and when my pager went off at 8:30 I almost came out of my white coat. I was between patients at the clinic where I am doing my Family Medicine rotation and I jumped to the phone to call home base. Busy. I gave it 5 seconds and called again. Ms. Virgina, the superlative secretary of the office, apologized for not getting to me the day before and told me they had good news for me. The rest of the conversation was just gravy. The Dean of Student Affairs came on the line to give me my score and with that I was officially an M3. The thing about the Step is that there are so many truly difficult questions to separate the top few percentiles of test takers that us middle of the packers are left somewhat bewildered. I mean I thought that my preparation was sufficient to get the job done, but when you come out of the test you just can’t be sure.

Friday was my last day in the clinic. The four weeks just flew by and I had a lot of fun. Most of the things I saw were pretty routine. Sore throats, headaches, hypertension, lower back strains, diabetes, etc. There was the occasional laceration to be sutured, the ingrown toe nail to be cut out, and a couple of flexible sigmoidoscopes to watch. Tomorrow I will begin the final two weeks of the rotation which are done at the Baptist Medical Center. One good thing about the M3 year it seems is the variety. If you don’t like what you’re doing one week, it’s OK because it will be liable to change the next week.

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June 23 2003

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My Family Medicine rotation began its second week today. Last Monday my group of 13 M3s, fresh from taking the Step, met at the school for our orientation. We have each been assigned to a family medicine physician around the state. The department really wants each student to get out of town and get some rural practice experience, but because of my family situation, I was allowed to get a clinic just outside of Jackson in a bedroom community. Most people try to get a town where they have family or friends that they can stay with, but others will end up having to live in a hospital room for the four weeks they are with their preceptor. The entire rotation consists of 4 weeks with the doc, and 2 weeks at Baptist Hospital, a local medical center. Our grade from the course will come from 5 components, each worth 20%. These include a written exam based on material from an assigned text book (Essentials of Family Medicine), a clinical skills exam using actors feigning various illnesses, a written assignment that includes a comprehensive history and physical, the NBME shelf exam, and a score given by the preceptor. Besides getting this info, the rest of the orientation consisted of a demonstration of the latest insulin delivery devices by a pharmaceutical rep who supplied breakfast and lunch, getting parking permits for the Baptist, and once again practicing the pap smear and flexible sigmoidoscope procedures on the dummies. We did this in ICM last year, but they wanted to give us one more shot at it. We were also told that this would allow us to tell a real patient that we had done these procedures before without necessarily mentioning that our prior subject, Jenny, was made of latex.

I got up early on Tuesday morning and made the 20 minute trip to my doctor’s clinic. He works with one other physician in a branch of a local chain called MEA Medical Clinics. A lot of people at the University refer to them fondly (or snidely as the case may be) as “Doc-in-the-Boxes.” It was my first meeting with Dr. S and I was surprised to find him a lot younger than I anticipated. In fact he is three years my junior and is only 8 years removed from doing his own M3 family med rotation. The first day I pretty much just followed him around and observed his techniques, but by the second day I was going into patient rooms and getting the chief complaint and history of present illness (CC and HPI in clinic talk) myself while doing the pertinent parts of the physical exam. In 5 days now, I have seen well over 100 patients. Most of the stuff is pretty easy and routine – sinusitis, pharyngitis, UTI, etc. Back problems are extremely common too. I have witnessed a couple of pap smears, helped with an abcess drainage on a guy’s butt, given a steroid injection, and done a few strep cultures.

Dr. S admits to a local hospital and does rounds about 6:30 in the morning. I have met him there a couple of mornings to see patients and we grab a free breakfast in the very nicely stocked physicians lounge. Clinic runs from 8:00 to 5:30 or so depending on how difficult the last appointments are. The staff is really nice, and I have spent some time learning how the whole office operation works. Three out of the five days, the ubiquitous drug reps have bought our lunch and catered it in. This is extremely popular with the staff and me as well! I have a friend who told me way back at the start of the M1 year that she wanted me to let her know the first time somebody called me Dr. Lee. Well of course I get called that a lot by classmates in a kind of looking to the future way, but this rotation is bringing the first uses of that sobriquet from regular people. And the thing that made me feel the best was during one of these freebie lunches. Orders had been taken for our choice from a local deli, and when the lunches were brought to the office, my bag had scrawled across the top in black Sharpie, Dr. Lee. Now that is too cool!

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June 6 2003

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The big day has come and gone. I took the USMLE Step 1 yesterday. The test is administered here in Jackson at a Sylvan Learning Center. They have a small room with 15 workstations set up with just table width partitions between them. I arrived at 7:45 for my 8:00 appointment and was greeted by about 8 of my classmates who were waiting in the lobby. One at a time we were taken back, signed in, assigned a locker for our lunch, study notes, etc., and put in front of a workstation to begin the battle. It was 8:15 by the time I got started. I zipped through the tutorial, and then knocked out the first two blocks of 50 questions before taking my first break. I got through blocks 3 and 4 before taking a lunch break. I had brought my First Aid book with me to the testing center, but I had no desire to look at any material during lunch. I got the last three sections completed and was out by 4:00 p.m. It feels great to really be through with the M2 year now but somehow there is also a nagging anticlimactic feeling as well. It will be up to 6 weeks before the results are in and I will be almost through my family medicine rotation before I learn my score. Overall I thought the test was very similar in difficulty and scope to the Kaplan Q-Bank. There were a few questions that were almost identical. The word handed down from upperclassmen is that if you were getting around 55% correct on the Kaplan questions, you would pass the Step and if you were in the 60% range you could expect to do just fine. The last few days before the test I was scoring around 65% so hopefully the conventional wisdom will prove correct. I heard somebody describe the relative difficulties of some of the prep questions out there. On a scale of 1-10 with 10 being the most difficult, they gave Med-Revu an 8, Kaplan a 4 and the actual exam a 3. I was a little discouraged because there seemed to be a LOT of questions that I just wasn’t sure about, but I think I tend to mentally minimize the number of questions that I felt positive about.

I had a very relaxing day today. I read the paper, worked the NYT crossword, and got a workout and hot tub bath in before seeing my kids closing ceremonies at the VBS they attended all week. In the afternoon, I picked up some beach clothes for next week at Old Navy, and went to the movies to see The Italian Job. This was one of the movies where the trailer had given up entirely too much of the plot. Of course if you saw the original (which I haven’t) then you know the plot anyway. It was pretty good but the chance to do anything fun without guilt was the real attraction. I even saw my favorite UMC librarian at the theater who asked “Shouldn’t you be studying?”

Tomorrow the whole family is heading to Lafayette, LA for Macey’s softball tournament and on Monday we leave for a few days in Destin.

The answer to last entry’s quiz was the subarachnoid space as most of you knew.

Oh yes, one other thing, I was paging back through some of my past entries and noticed that some comments had been posted since the last time I saw them. Some of these were obviously fairly dated and asked questions that I never responded to. The deal with the comments is that they get posted on the page of the original entry and the diary writer gets no notification. I don’t know if you posted anything unless I manually go back and check. If you asked me anything via a comment and I didn’t respond, that was the deal. You can reach me or any of the other writers via the “Email writers” link in the top left corner. If you want a reply, be sure to supply your correct email address on the form provided. I have heard from a whole bunch of you out there and I appreciate all of the comments! Take care and I’ll report back after my vacation!

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