the condition known as msc

also known as “medical student castration”.  it’s the position you are put in by the fact that you are not allowed to place orders and no one generally cares what you think.  if you’re lucky, you might be able to express your own opinion – that’s assuming you agree with everyone else.

you might be wondering where this newfound bitterness stems from – and it certainly is newfound.  it’s primarily from my chief resident right now.  as an m4, i no longer answer to an intern.  in fact, i don’t even see them.  this is a pretty major change from m3 year where the lower-level residents were the only ones you had contact with. 

here’s the problem:  we have a patient with a history of chronic pain who is on medications A, B, and C.  she had her surgery to rid her of one of her origins of pain – a retroperitoneal cyst.  there is no guarantee that this has been causing her pelvic pain, but it seems likely.  she had an exploratory laparotomy (the opened her up, unlike laparoscopy where they put in little holes), and we probed around in her bowel, took stuff out, sewed her back up.  regardless of her history, this is a procedure that inevitably will cause the patient pain, pain, pain.   any other patient with this surgery would be getting plenty of pain medication.  the situation become sticky because she is already on pain medication – which means, she needs MORE.  even though we have fixed a potential source of her pain, she’s still going to have pain just from the surgery.  so what do we do?  we give her medication A and B, and a mere fraction of what she normally gets of C.  this will inevitably amount to inadequate pain control.  so inadequate that i walked into her room with her hunched over crying in pain.  i tell my resident and what does he do?  brushes me off.  and therein lies the castration.  here is a patient in a lot of pain, and i can’t do anything to help her.  it’s keeping her up through the night, and she has no appetite.  but wait! there’s more!

she quit smoking about 3 days ago, and for those of you quitters out there, you might recall that counterintuitively, after you quit you have an increase in mucous production.  at face value it doesn’t make sense, but, when you realize that smoking paralyzes the cilia of the lung cells which move the mucous out, you would know that the mucous then accumulates.  when you stop smoking, those cells egt back into action, but now they have lots of catching up to do!  so lots of coughing up mucous.  this is her next situation, except guess what!  when you cough, you increase your intrabdominal pressure, which hurts alot when you just had an invasive surgery down there. 

so then i ask him if we can either give her a breathing treatment or something to help her with this mucous to loosen it up.  i don’t want to give an expectorant because then she’ll cough more and with her pain not controlled i hardly would want her to go through that.  and a suppressant doesn’t make much sense because it’s not a dry cough – we need that stuff out.  well he refuses the suggestion of a breathing treatment (in addition to any change to her pain medications), but finally after much nagging he does give a crappy suppressant.  hey hopefully at some placebo effect contributes.

so what’s a student to do.  like i said, i can’t order anything.  i can’t call the attending because i can’t go over my resident’s head, but here i am concerned about my patient who is entirely dissatisfied with her care (a large part due to her pain) and no one can explain to her what’s going on, least of all me because i’m definitely left out of the loop.  it would be one thing if i was doing this for some ulterior motive (although i can’t even fathom what one might be), but really i just want to help the patient and to learn how to take better care of them.  this isn’t a battle for who is right.  i just want the damn patient to be happy and as comfortable as possible after her surgery. 

fortunately, the patient asked if she should call her doctor, and i said, as a private patient, you are absolutely entitled to discuss your care with your doctor.  i wouldn’t have even said that if it weren’t for the advice of another resident i frequently turn to for advice. 

i guess ultimately it is just extremely frustrating when every effort you make to help a patient is not percieved as such.  he honestly just gets irritated when i make suggestions without explaining why not.  so really, what is a medical student to do?

 

i also should note that this same resident tells me NOT to write down what physical findings i find on a patient.  i am literally NOT allowed to write tender to palpation.  i have to check with him.  as though i can’t assess when it hurts to palpate an abdomen.  i am also NOT allowed to write down what MY assessment and plan is.  so really – why am i even writing a note.

honestly, i think tomorrow i’m going to talk to my favorite attending, because i am at my wits ends.  i have never been so stressed out about this kind of stuff.  fortunately, i have been able to hide it all and i’m nice as ever to the resident.  i’m more concerned about the other student who will be working with him in a matter of 4-5 days.  oh well – i will try to prep her before she starts.

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