No means no

I was in the hemodialysis unit recently, chatting with a patient about how his life had been affected by HD and how he generally feels. As corny as it may sound, I find these touchy-feely encounters with patients to be incredibly rewarding and informative. I think those of us who are healthy underestimate the impact of chronic disease, but simaltaneouly underestimate people's adaptive resiliance. This summer I have been fortunate to have several one-on-one opportunities, but group interactions of this kind are a regular part of our medical school curriculum.

Anway, this one was especially awkward because the patient proposed to me several times and repeatedly offered to have my children. He was neither demeted nor joking. He wanted to take me out to dinner that night and put a ring on my finger. He thought it was a genetic imperitive that I breed because I (apparently) am "drop-dead gorgeous and a genius." Just about every question I asked was answered with some variation on this theme (along with some genuine insight into renal failure) for almost two hours.

An example interaction:
Me: Do you have other health problems too?
Him: I'm healthy enough, if you know what I mean; no disrespect.
Me: How about high blood pressure or high cholesterol?
Him: Yes, I got both of those, lady.
Me: Are you on medications for them?
Him: Yes, but I don't take em. I don't believe in pills. I seen to many people die from pills.
Me: I suspect those were different kinds of pills. It's important that you take your medicines.
Him: I feel fine. I'll take them if you hand them out though.
Me: Your health could get a lot worse if you don't control your blood pressure and cholesterol. You want to make it to transplant don't you?
Him: I would take them if I had you to come home to, lady.
Me: Do you live with anyone now?
Him: No, you can move right in. I'll take you out to dinner tonight and put a ring on your finger.

Liver #2

I went to bed excited because we had consented another patient for our liver transplant study. The OR schedule said they would induce the anesthesia at 10:30am, so I hit the sack just before 2 with my alarm set for 9. At 4:46 my pager goes off. They are inducing now. I head straight to the OR where I find out that this is expected to be a tricky case. I have had 3 hours of sleep and haven't eaten since 8:30pm the previous night. I emerge from the OR at 10:30am, put the samples on ice and head straight to Einsteins for a large coffee and a honey wheat bagel with honey almond smear. Never tasted so amazing.
The surgery itself was longer than the last one I observed, but they didn't have to use any blood products and were able to extubate before sending the patient to the SICU. It speaks to the skills of the surgeons and anesthesiologists in managing the anatomy (surgeons, no blood) and physiology (anesthesiologists, not acidotic).
The patient was awake when I went up to the SICU for the 2 hour post-op samples; the family was there too. It's really kind of fun when you can say you were in there with the patient the whole surgery.
I left the hospital around 2:45pm and was kind of dragging this afternoon, but I just had some coffee and a chocolate chip cookie. Nothing like caffiene and glucose to keep yourself on point.
There's another harvest this afternoon. If they keep the liver in house there's a chance I'll have another surgery this evening, although it looks like the graft is of poor quality, so I may get some sleep instead.

Crystal ball

Before medical school I took a quiz to see which medical specialty I should be. Those answers are here. I retook it now (beginning of M2 year) to see if it's changed at all. Apparently, the new list is:

1. Thoracic surgery
2. Urology
3. Plastic surgery
4. Orthopaedic surgery
5. Ob/Gyn
6. Nephrology
7. Neurosurgery
8. Infectious disease
9. Cardiology
10. Nuclear Medicine

Apparently I am straying farther into surgery and surgical subspecialties. It is worth noting that the quiz does not separate pediatric specialties from adult. If I remember, we'll try again after third year and see if I'm any different then.

Don't tease me!

(18:21) I get the email that there is to be a liver transplant at 20:30.
(20:07) I get the page that says the transplant will begin 21:00.
(20:14) I get the page that says the transplant has been canceled.
(22:00) I go out dancing instead.

Turns out carrying a pager in a club makes you attractive. A law student asked for my phone number.

Cirrhotic liver. The kind you take out, not put in.

Big trauma

A class one rolled in with the survival flight paramedics; he had been broad-sided in a MVC. He looked to be in surprising good shape: unstable pelvis and dehydrated, but good vitals, responsive pupils and moving all four extremities. The CT scan, however, told a different story and he went up to the OR emergently: 3 perforations in his bowels, multiple pelvic fractures (with bleeding) and an aortic dissection. He went straight from OR to IR to BICU... we'll see how he does.

Yet more trauma

It started off well. I was studying in a coffeeshop when my trauma pager went off. It's silly, but I felt a little cool reading the page out to my friend and booking it out of there.

"Class 2 M, Go cart vs truck, blunt, 115/78, not intubated, unk GCS, ETA 8 min"

It turned out the patient was pretty much ok - just a closed tib/fib fracture. He had been transferred to our hospital mostly because of questionable change in mental status, which it became quickly clear was not the case.

On my way back to my car to drive home and contine studying (well, doing write-ups on clinic patients) the pager goes off again (in front of more people!).

"Class 1, M, ATV vs tree, blunt, 123/80, intubated, GCS 3, ETA 10 mins."

It turned out ATV vs tree was actually fell-off-the-back-of-moving-pickup-truck. For those non-medical folk, GCS of 3 is very bad. It's a scale of 3-15 based on eye opening, movement and vocalization. A 3 means you have none of the above. He displayed from priapism (look it up if you don't know), indicating decreased sympathetic tone. On CT he had an impressive skull fracture and significant uncal herniation.

While eating a delayed dinner, the pager again beeps.

"Class 2, M, dirt bike accident, GCS 15, not int, in ER"

Five minutes later...

"Adult, class 2, motorcycle accident, left ankle lac, 148/68, HR 118, GCS 15, ETA 5mins"

More trauma pages

The trauma pager has beeped a few more times and I've seen multiple bike vs. car and a falling off a 30 foot ladder. Think chest tubes, intubation, consults with a neurosurgeon and lot of leg fractures. Any thoughts I had of becoming a bicyclist are definitely out. Mostly I just watch the trauma team in action, but occasionally I get to do things like put a gown on the person, stabilize the neck while rolling him.. small things of that nature.

I've also had two more gen med clinics. Yesterday's was particularly cool because Dr. K went in and did the appointment (without me), then sent me in to try my hand (observed by Dr. P). I asked my questions, did a limited physical exam and then explained what I thought it was and attempted to address the patients concerns and questions. Upon debrief with Dr. K and Dr. P... I got it RIGHT! I successfully diagnosed a real patient based only on information I gathered myself in real time. I have to admit, that felt really really good.

There was a second ego boost later in the day when the M4 on trauma rotation was quizzing the M3s on surgery about thoracotomy and pneumothorax. M3s didn't have a clue (and I knew all the answers, but kept my mouth shut because no one likes a show off). The current M3 class has been running around patting themselves on the back for their record-breaking board scores (their average was the highest at UofM ever), but they are being outdone by lowly little M2s in the trauma bay.

Caught

Rounds just ended. I did fine on the first half where we are walking from room to room. Even saw a man with 27% of his body surface burned by a bbq. Also saw a compartment syndrome fasciotomy on the anteriolateral lower leg. THEN we went to the conference room and went through another hour of patients just talking.... talking in a dim room... sitting down... after I'd been up all night... I REALLY tried to hold it together.

The trauma surgeon who was in the trauma bay over the weekend walks out of the room with me.

"Looks like your coffee is wearing off. Fighting a losing battle there."

And now I'm completely ashamed. Ashamed and embarrassed. And still really sleepy.

My first overnight

It's the morning of my first overnight in the hospital. I was here from 10am-4pm on Sunday getting samples for anesthesia and working on charts for cardiology. When I checked my email on arrival at home, I found out there was going to be a liver transplant that evening. I took a quick nap, ate some food and headed back to the hospital. I spent the night in the OR, pestering the anesthesiologists with questions and asking for samples. Did you know that post liver transplant the person will have no gallbladder? I spent the wee hours of the morning processing the blood and urine. I just returned from putting it in the -20/-70 freezers. In less than two hours I have trauma/burn rounds, after which I will run home to shower/change into professional dress and return to the hospital for noon conference and trauma clinic. At about 6pm I will be able to go home and crash. And you know what? It's fantastic fun!

Hide and seek

I was getting some ice to prepare for the samples I am getting today when two doctors approached me. Keep in mind I am standing at an ice machine in an otherwise empty pre-op unit (non-emergent surgeries are not scheduled for weekends, especially not holiday weekends).

Doctor: Have you seen a big fat man?
Me: Excuse me?
Doctor: We're looking for a patient, Mr. L. He's ginormous, you couldn't miss him.
Me: I'm sorry, I haven't seen anyone like that.
Doctor: If someone was going to have surgery, where would they be pre-op?
Me: Here, but it's a weekend.
Doctor: Yes, I know, but we've lost him you see. He's missing.
Me: Sorry.

I'm not sure what's more concerning: that fact that they have managed to lose a huge fat patient or that the doctors had to ask the medical student where patients go pre-op.

First pages

This weekend brought the first liver transplant since I started taking anesthesia call and the first trauma page on my trauma block.

For anesthesia, my friend J was on call of the intra-op samples (I'm jealous) but I've been going in to the surgical ICU every day to take blood from the arterial line and urine from the Foley for processing. I'm sure there will eventually be a liver on my watch and I'll get to go into the OR.

For trauma, I booked it down to the trauma bays to watch the team take care of a young adult with an open tib-fib fracture from a motorcycle accident. I was hoping July 4th would be a heavy trauma weekend, but so far - not so much. Let's hope it gets busier over the next two weeks.

Ok, so I realise that my hoping for livers and trauma requires that people get sick and that it makes me a tad bit of a bad person. But really, these things are going to happen; I just want them to happen here (as opposed to in OH or some other place that I am not).