Wednesday, March 28, 2012

Dirty jobs

Every doctor has some area of medicine that they flat out don't like.  I am no exception.  In fact a lot of physicians choose their specialty not based on what they like, but rather by avoiding what they don't like.
As a medical student, I was dead set on going into family medicine.  All that changed, however, one dreadful day after witnessing an unpleasant delivery.  We had a very petite 16 year old female with gestational diabetes who was set to deliver her son.  All was going well - her contractions were regular, baby was doing well, and she was comfortable after getting an epidural.  Little did we know that she had a 9 lb baby squeezing through a birth canal that would have been too small even for a 6 pounder.  This kid's head was enormous.  I didn't have much experience at all in obstetrics, but even I could tell this was not going to fit.  As the head descended slowly down, I was told to glove up and 'stretch out the vagina a little bit.'  Ummm, what?  Ok, here goes nothing.  I gown and glove up, get the boots and mask on, and do as I'm told.  As I'm stretching things out gently, I feel the tissue start to tear under my fingers.  Oh geez.  That didn't feel good.  Blood starts oozing out, then it drips, then is really starts coming out.  Then she gives a big push and poop flies everywhere.  Miracle of birth my ass - this is disgusting!  About this time the baby's heart rate starts to drop and I really don't remember things too clearly from that point.  I got shoved out of the way by someone above me in rank and somehow they got this massive child out of the mother, but not without tearing the posterior part of her vagina all the way down through her rectum.  I stood there horrified.  This poor girl's pelvis was now opened from top to bottom like a book.  I'm not sure how her legs didn't just detach from her pelvis and fall off.  

Next thing I know my hands are getting extremely warm.  Recall that I'm in a gown, gloves, mask, and hat.  Wow, now my head is sweating, and my mouth is getting extremely dry.  For the love of Moses, why is my vision narrowing so fast?  Then it occurred to me that I might just faint if I don't get out of there.  And heaven forbid I faint and fall forward on the bloody battlefield in front of me!  Damn it all - I'm going down!  I rip off my mask, pull off my gown and gloves, and bolt right for the door as fast as I can.  I stumble out to the nursing station and fall into the first chair I see and put my head between my legs.  I wondered if this is what it feels like to die.  Seemed like a good option at that point - that's how bad I was feeling.  It was just then that I heard a nurse yell across the pod, "Oh my God!  The nursing student is about to faint!  Get him some juice!  He's pale as a ghost!"  I sat there for a good 5 minutes with wounded pride, sipping on my juice and contemplating my future as a family practitioner and having to deliver babies as part of my training.  No way, screw this.  I never want anything to do with that again!  Later that afternoon I walked over to the internal medicine department, set up a rotation, and the rest is history.

So I suppose it's good to get exposed to all sorts of nasty things so that you understand what you really like or don't like.  Looking back, I'm glad I had that experience. 

That's not the only thing that has grossed me out.  As a matter of fact, there's no shortage of things to be grossed out by in medicine.  The grossness is limited only by your imagination!  If I were to make a list of things that gross me out, it would look something like this:

6. Nonhealing wounds

Have you ever seen a stage 4 pressure ulcer?  How about an infected one?  Omg I can't handle the sight/smell/feel of these.  There are nurses/physicians who only deal with chronic wounds, which is just unfathomable to me.  I could never do it.  

5. Poop

Do I even need to explain this?  Believe it or not there are doctors out there who specialize in poop (gastroenterologists).  Wonder why they do it?  Because they get paid handsomely for it.  Cut their salaries down to primary care level and the specialty wouldn't even exist.  Think regular poop smells bad?  Take a whiff of bloody poop (especially an upper gastrointestinal bleed) or c. diff poop and you'll be gagging for a week.

4. Childbirth

Not so bad when it goes well, but it just isn't my thing.  As if making me physically ill wasn't enough, I also had a good pair of dress shoes ruined during medical school when a baby came too fast and I didn't have time to get my boots on.  I can still remember the feeling of warm, meconium-filled amniotic fluid bathing my lower extremities.  Yuck.

3. Unkempt obese people

There's nothing like examining between the rolls of a super obese patient and finding some strange, smelly, disgusting goo of uncertain etiology.  The closer you get to the groin, the nastier it gets.  Sometimes is so old that it's crusted over and stuck to the skin.  I think I just barfed a little bit in my mouth.

2. Mouths

Speaking of mouths, do you know what the dirtiest orifice on the human body is?  Actually it's the anus.  But the mouth is a close second!  For some reason I'm just disgusted by the oral cavity.  I'd rather be a gastroenterologist than a dentist.  Even mouths with good hygiene are repulsive.  One look inside a meth mouth can ruin my day.

1.  Vaginal discharge 

As gross as all the others are, this one takes the cake.  Hands down winner.  Not even close.  Can't think of anything that ruins my day more than this.  Thankfully this isn't common in the hospital, and if it's even an issue, it's usually something more serious than I feel comfortable dealing with and I usually punt to gynecology.  If you like emergency medicine, get used to it.  But thankfully not many people are admitted with vaginal complaints.   Clinic, however, is a different story.  When I see this chief complaint on the clinic schedule, I secretly hope that the patient doesn't show up.  If they do, then how I handle it depends on what kind of mood I'm in.  If I really don't feel like dealing with it, I refer them to gynecology.  I send cardiac patients to cardiology and surgical patients to surgeons, so why wouldn't I send a vaginal problem to a gynecologist?  I'm an equal opportunity referrer.  If there are people out there who like treating diseased reproductive organs (you know who you are, gynos and uros!), who am I to keep them from fulfilling their dreams?

One of the nice things about internal medicine is that you can always refer someone to a specialist if you don't feel comfortable handling something.  Is it cost-effective to refer problems to a specialist that in theory I should be able to handle?  Probably not.  Would the old-school physicians scoff at me for doing this?  Probably.  But I do it anyway.  I don't abuse it, and in fact I don't like to refer most things out unless I feel it needs to be addressed by a specialist.  But there are just some aspects of medicine that I'm not good at or don't like doing (usually they go together), and so I refer them out. 

I'm glad there are specialists out there.  I think I would get bored seeing the same things over and over and over again.  Each of us shoulders a bit of the unpleasant load and collectively we do a pretty good job of taking care of the 'dirty work' in medicine.

Lest I not give credit where credit is due, I should point out that the majority of the dirty work in medicine is not actually done by doctors.  We all deal with it and are involved to some extent, but by and large nurses handle most of the dirty work themselves.  I have tremendous respect for the work they do.  Day in and day out they clean, bathe, groom, change, wipe, and feed their patients.  And they are expected to do it all with a smile and treat them with the utmost respect.  So props to all the nurses out there for doing what you do, because I would be terrible at it.

Now that I've let you in on another secret of the inner workings of internal medicine, I hope you aren't displeased.  Remember, we too are human beings.  We have likes and dislikes, just like you.  And like it or not, it's part of our job, so we get it done.  Perhaps next time you see your internist and he has a referral printed out and signed before the word discharge even leaves your mouth, you'll know why.

Stay tuned.

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