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What he does...

What I do...

Dutch Thanksgiving

Reasons I don't generally go home for Thanksgiving:

1. It's six hours and three time zones away by plane

2. We're European, it's not really a family tradition

3. Most of the food is not on mom's Atkins diet

Lucky for me I have generous friends and am usually adopted by someone else's family on a temporary basis. For the past two years, it has been by AH, a classmate. Her family, back in the day, were Dutch and oma (grandma) in particular finds my authentic Dutch self charming. Last year she had me read a Dutch cookbook and indicate which foods were familiar. So this year I baked some Boterkoek and brought it with me. It's super simple and looks fairly plain, but let's face it, anything that's 25% butter is going to be tasty. I like mine with a hint of almond flavouring.

Try something Dutch:

1 cup butter, softened

1.5 cups granulated sugar

2 eggs

1 tablespoon almond extract

2.5 cups all-purpose flour

1.5 teaspoons baking powder

Mix butter and sugar. Add eggs, 1 at a time. Add remaining ingredients. Press into two 8" pie or tart tins. Bake for 30 minutes at 350 degrees Fahrenheit. For best texture, leave uncovered for 12-24 hours. Thereafter, store in an airtight container.

Emergency Dept: week 4

Monday: chest compressions and a resident too busy to staff with me
Tuesday: no cath for you, more abdominal pain
Wednesday: just had his nose done and now it's broken, back pain, allergic reaction
Thursday: it's not your shunt but we'll scan you anyway, can't stop pooping
Friday: exam (that doesn't count)

Emergency Department: Week 3

Monday: name that heart rhythm...
Tuesday: just plain crazy x2, abdominal pain
Wednesday: off! pumpkin surgery.
Thursday: immunosuppressed and febrile, attending gave me homework?!
Friday: chest compressions, large bore IVs and a bladder scan
Saturday: mr anxious, mrs crazy and the guy smoking though lung cancer
Sunday: off (again)

Emergency Dept: week 2

Monday: Lupus, vomiting blood, strep throat, passing out.
Tuesday: Multiple orbital fractures, pelvic exam and a cheerleader with the flu.
Wednesday: Tech shift - peripheral IVs, appendicitis.
Thursday: Splints x3. Asthma. Oops, the baby ate mommy's pills.
Friday: Stitched up a chin, a forehead and an ear.
Saturday: Biliary colic, drunk, drunker and drunkest.
Sunday: off

Emergency Dept: week 1

Monday: orientation. started an IV on a classmate.

Tuesday: orientation. splinted a classmate.

Wednesday: abdominal pain x2, chest pain and hypoglycemia. started an IV.

Thursday: seizure, abdominal pain x2, chest pain. did an NG lavage and placed an a-line.

Friday (peds): poison ivy, lip abrasion, abnormal labs, abdominal pain, seizure

Funny thing about that poison ivy... the little boy had a small patch of it on his hand and a big patch of it in his groin area...

really?!

Me: What illnesses run in your family?

Patient's mother: My high blood pressure was giving me seizures so they took out my spleen.

Emergency Medicine orientation

"Sometimes the facial structures are traumatized, complicating the intubation. Although, it is a lot easier to get the jaw and tongue out of the way when they are disconnected."

"You want to make sure the NG tube is not in the lungs; it can't really decompress the stomach from there."

"He came in with a skeleton of a finger, no flesh, and said 'fix me.' Well, sorry dude, you're f*cked. There's no saving that finger. Degloving injuries require amputation."

"In Europe, not everyone who goes into a trauma bay gets a rectal, but here we log roll everyone and do a rectal exam. The surgeons love it."

it shouldn't bother me, but it does

I'm talking about medical inaccuracies on television. We won't even get into the inaccurate representation of resuscitation, which is so egregious that there is published research on it. Recent errors I've noted:

1. Nurses, unless they are CRNAs, don't intubate patients.

2. There is no such thing as part-time medical school.

3. You don't get a long white coat at the white coat ceremony, you get the short one.

4. Diabetics requiring insulin do not leave needle impressions on their hip bones.

5. Hospitals cannot turn away acutely ill patients because they don't have insurance.

6. You are not forbidden from speaking with a person after neurosurgery because getting them emotional could cause their brain edema to worsen.

7. If you coded, you would be moved to an ICU, not put on a stretcher along the hallway. And a lot of people would show up, not just one nurse.

8. I don't care if there's a killing spree, a random nurse would not be authorized to read confidential patient data (about a potential victim) over the phone to a police officer. She would be fired.

9. If a trauma victim is talking, they don't go straight to the OR. They go to the ER to be stabilized or for images. There is no magic hallway connecting the outside door to the OR.

10. If you sprained your pinkie finger, you would not have a hard cast placed on your hand.

Another time I'll let loose on the absolutely ridiculous depictions of medical school. I have yet to see anything that remotely resembles actual medical training on television.

Quatrains

I'm apparently late to the party, but I just stumbled across the poet Rumi. Some favourites:

You think you are alive
because you breathe air?
Shame on you,
that you are alive in such a limited way.
Don't be without Love,
so you won't feel dead.
Die in Love
and stay alive forever.

It is your turn now,
you waited, you were patient.
The time has come,
for us to polish you.
We will transform your inner pearl
into a house of fire.
You're a gold mine.
Did you know that,
hidden in the dirt of the earth?
It is your turn now,
to be placed in fire.
Let us cremate your impurities.

I am so drunk
I have lost the way in
and the way out.
I have lost the earth, the moon, and the sky.
Don't put another cup of wine in my hand,
pour it in my mouth,
for I have lost the way to my mouth.

More at http://www.rumi.net/rumi_poems_main.htm

Little m, big P

It occurs to me that I haven't really talked about residency applications, which actually comprise a lot of time and mental energy during the beginning of M4 year. I'm applying for a medicine-pediatrics residency. It's a four year program, at the end of which you sit the boards for both internal medicine and pediatrics. You are then eligible for any fellowship in either medicine or pediatrics, though 60% of graduates go into primary care. Not me - of course - I will be headed to fellowship.

There aren't very many med-peds residency programs, and each one takes very few candidates. Thus, this residency is competitive because demand outstrips supply. Nevertheless, my advisors tell me I will match.

For those of you who don't have relatives in medicine, I will briefly mention what "the match" is. Basically, as a 4th year you apply to some residencies. The ones interested in you will invite you to interview. You rank all the places you interviewed. The hospitals rank all the people they interviewed. It goes into a big computer program called the NRMP. In March you get an email telling you where you matched - not all the places, just the one place you will go to. It's not a choice and you are not guaranteed to be chosen anywhere. Rather appropriately, this process causes a tremendous amount of anxiety - will I match at all? Will I match somewhere I actually want to go?

Right, so I've been told I will match, it's just a question of where. My current list of programs is 19 deep and I hope to get 10 interviews. I've had to get four letters of recommendation, two of which must come from the chair of the peds dept. and the chair of the internal medicine dept. I have to get a letter of endorsement from the dean of the medical school as well. I have to put my CV and all my publications into the online program (one item at a time). I have to provide transcripts and copies of my USMLE step 1 and 2 scores. I have to write a personal statement and include a photo. I have to pay money (of course). All of this gets submitted September 1st, so you can imagine the past three months have been spent getting all of this together. But soon - so soon - I hit submit and then... I wait. Wait and hope. Hope for interviews.

I will keep you updated.

Heartbreak cardiomyopathy

This month I had a patient with an interesting and rare condition called TakoTsubo Cardiomyopathy, also known as "broken heart syndrome." It involves myocardial stunning after a highly stressful event such as the death of a spouse or a natural disaster. Basically, you are so overwhelmed that you literally go into heart failure. The physiologic mechanism is incompletely understood, but leading theories revolve around catecholamine release. Thankfully, the significant majority of people recover their full heart function in days to weeks. It is most commonly seen in Japanese post-menopausal women, however it has been described in the US and Europe as well. It can be accompanied by an NSTEMI (heart attack) and frequently QT prolongation (repolarization abnormality - sorry, I don't know how to translate that better without a tutorial on EKGs).

It gets its name from Japanese octopus traps. Why? Because this particular heart failure displays what we call "apical ballooning." Basically, the upper and middle parts of the ventricle contract, but the apex (the point) of the heart does not. That means that blood, which is ordinarily squeezed from the bottom of the heart towards the top, is now being simultaneously pushed up and down. the down-going blood has nowhere to go so the tip of the heart balloons out (see diagram).

My patient began recovering heart function very quickly, but her QT prolongation was impressive. Almost write-it-up-in-a-journal impressive. Thankfully, that also resolved quickly. We never got a good sense of what her precipitating event was, but I suppose all stress is relative.

Welcome to M4!

One whole week into my fourth year you may be wondering, what have I done with myself? Well, I am starting the fourth year much the same way I started the third year: studying for a USMLE exam.

This week I have covered cardiology, dermatology, GI, endocrine, biostatistics and some infectious disease. I am reading, highlighting, making flashcards and doing lots of practice questions. Fun fun.

However, life is not all work. I had a lovely day and night out (we started a little early) after completing third year: there was sangria, there was gin, there were pancakes the next morning.

I've also been helping to orient the rising M3s, which is a nostalgia-inducing process. It really makes me realise how far I've come in the last year in terms of my comfort in talking to and evaluating patients. It also points out how different the focus in teaching is now - I spend much more time thinking about details: drug choice, dosing, treatment length, etc - whereas before it was about having a workable list of potential diagnoses. A lot of what I struggled with at the beginning of my third year is assumed knowledge in the fourth. My review books don't even bother to classify antibiotic types, for example, it's assumed I know azithromycin is a macrolide that acts on the 50S ribosomal subunit and has good efficacy against gram positives and atypicals. The new questions is: how much and how many days worth for a patient with strep pharyngitis in a COPD patient?

In an effort to stay balanced while studying, I've joined a tennis clinic. I had my first practice yesterday and got a little sun (oops) as well as losing half a toenail jamming my foot in my shoe on some abrupt directional change. Worth it. I'm horrendously inconsistent at the moment, but I hit a few aces and a couple of solid put-away shots. I'm considering joining a USTA team this summer, but I'm not sure I'll have time with the sub-i's etc.

Motorcycle lessons start next week and I'm now involved with admissions for the medical school too - so hopefully those will yield some good stories for a post. In the meantime... nose to the grindstone to (hopefully) pull out a good Step 2 score.

?! #492

I was reading a NYT article on hospital compliance with hand-washing when I came across this gem of a comment:

"I'm confused. I thought the only way hand washing would kill bacteria is if the water was boiling hot."

Um, have you heard of SOAP?

Little old man

I had a cute four year old patient today with two old-man problems: a bald spot and urinary hesitancy. His mother brought him in because of the bald spot: an oval stripe towards the front-top of his head roughly the size of a kiwi. It first appeared a month ago as a painless, small spot the size of a dime and it had steadily grown. He was otherwise well.

While the attending conferenced with his mother, he came up to me and announced "I have to go potty!" I took him by the hand and we walked to the clinic bathroom. I waited outside the door. Thirty seconds go by and I hear "Mr. doctor. Mr. doctor!" I crack the door and he's standing there with his pants around his ankles. "I want to use the giant bathroom!" I pull his pants up, take him by the hand and walk him to the other end of clinic where a more spacious bathroom is located. Again, I wait outside the door and soon hear "Mr. doctor, mr. doctor!" I crack the door. "I'm scared!" I enter the bathroom, kneel and say "How can I help you? Do you want me to lift you up or get you a stool to stand on?" He replies "I just kidding. I don't have to go potty!"

The question everyone in the office is asking me all day: what happened to that little kid's head? The answer: he's pulling his hair out.

Maybe the grown-up sized toilet at home is freaking him out.

PIckled penis

One of my preceptors recently taught me about a physical exam that was commonly done in the late 1980s: androscopy. It's an exam aimed at finding and treating HPV warts on the male genitalia. It is analogous to a (cervical) colposcopy in women.

The male is undressed from the waist down and lies on the exam table with feet in stirrups - similar to a woman undergoing a pelvic exam. The genitals (penis, scrotum, perineum) are wrapped gauze soaked with vinegar for five minutes and then inspected with the naked eye and with the colposcope (a special microscope). Lesions, if present, may be excised, cauterized (acid or freezing), or laser vapourized.

Interestingly, a pub med search has revealed that 51-65% of men who were clinically asymptomatic had lesions on their genitals when viewed under the microscope. However, up to 20% would continue to be seropositive for HPV even with negative follow-up colposcope exams; suggesting that androscopy was not eradicating the disease from the male population. For that reason, and because penile cancer is a very rare complication of male HPV, the exam was largely abandoned as routine practice.

It may come back into favour for the rectum, however, as anal cancer rates increase. Just as we now recommend screening anal pap smears for persons practicing anal intercourse, a vinegar anoscopy of the anus would be a logical follow up exam for a positive result.

For the men out there - yes, they put vinegar on the cervix for a colposcopy.

Let's talk about sex, baby

Lately, there has been a lot of talk about sex. From the lecture I had today on contraceptive counseling to the recent public debate over federal funding for Planned Parenthood to the omnipresent national abortion conversation. For some reason, I thought that people had at least some basic knowledge about sex and contraception from either their parents or their junior high health classes or, hey, the internet. Apparently this is not the case, so let's clear a few things up.

1. “The fact is that 95 percent of the contraceptives on the market kill the baby in the womb,” said Jim Sedlak of the American Life League.

INCORRECT. The American College of Obstetricians and Gynecologists defines pregnancy as beginning with the fertilized egg’s implantation. Even if you believe that life begins prior to that - at the joining of sperm and egg - the majority of contraceptive measures intervene BEFORE the sperm and the egg meet. Let's review:

a. Hormones (aka the pill) - birth control pills prevent a woman from ovulating. If there is no egg, there is nothing for the sperm to fertilize and thus no baby is formed. The pill also has the happy side effects of decreasing the risk of ovarian cancer, reducing acne, and decreasing period-related pain. There are plenty of reasons women take the pill that have nothing to do with sex; it is a first line treatment for dysmenorrhea, endometriosis, ovarian cysts and fibroids.

b. Intra-uterine device (aka IUD) - One form of IUD, the Mirena, contains hormones and thus partially acts via the same mechanism as the pill. All IUDs also cause alterations in cervical mucus, which prevent sperm from being able to fuse with an egg. There are enzymes in cervical mucus that aide the sperm in 1) getting to the egg and 2) penetrating it. Without these cervical enzymes, fertilization does not occur.

c. Condoms - okay, I should hope this is self-explanatory. If the sperm is in a wrapper and not in the vagina, it's not going to make contact with an egg and create a baby.

2. If I have anal or oral sex then I won't get STDs.

INCORRECT. In fact, if you are having anal sex you should be getting regular anal pap smears. A cotton q-tip is swabbed in the anus and the cells analysed the same way they are for a cervical pap smear. HPV will do the same thing to the cells in the anus as it does to the cervix: cause cancer. Recall that some strains of HPV do not cause symptoms so you're not safe just because you don't have warts. Famous case: Farrah Fawcett died of anal cancer. HPV has also caused a rise in mouth and throat cancers, however we do not routinely swab for oral HPV at this time.

3. Guardasil (the HPV vaccine) is only for girls.

INCORRECT. It has been FDA approved for men as well. Men can transmit HPV to their sexual partners and, when infected, HPV causes an increased risk for penile cancer (still rare though). HPV will cause anal and oral cancers just as effectively in men as women.

4. “Fertility and babies are not diseases,” said Jeanne Monahan of the Family Research Council’s Center for Human Dignity

SORT OF. Many physicians consider pregnancy a natural and healthy state; however it does have a diagnosis code (an ICD-9) and it does dramatically and sometimes permanently alter the physiology of the mother. If it were totally benign we wouldn't require so many pre-natal visits, lab tests, ultrasounds and testing. There are diseases a woman can have that make pregnancy a clear and present danger to her health, even potentially fatal. There is also the issue of implantation in an abnormal part of the body (ectopic) which is also extremely dangerous to mom.

Public debate is healthy and I don't expect everyone to hold the same opinions as me; however I think is important that we are at least factual and informed about the topic. Let's not pass laws in ignorance.

Extra-curriculars

A friend recently made me aware of the BANF film festival, which had a showing in town over the weekend. Talk about inspiring! It's essentially all movies about extreme athletes of some kind: mountain biking, whitewater kyaking, speed freeclimbing, etc. Two movies stuck out for me at the showing for both their striking visual content as well as their kick-butt soundtrack choices:

LifeCycles

Song: Saskatoon by Data Romance (this is a remix of Levee Camp Holler)

The Swiss Machine

Song: Welcome Home by Radical Face

I called it!

Warning: this post involves some bragging. Let me state that I frequently get things wrong (thus, still in training), but that's not as fun to write about.

How clinic works: The attending sends me in to each room ahead of her to get a history and perform a physical exam. I then briefly present the patient to her as well as any recommendations I have. She then finishes the appointment with the patient (I'm in the room too).

I go in to see patient X who is supposedly here for a routine physical. I ask her how she's been feeling lately and she says "my optometrist said it was important I keep this appointment." On questioning I discover that she is having positional headaches and some intermittent nausea, but otherwise feels well. She denies any vision changes.

On physical exam, patient X had bilaterally blurred optic disc margins (papilledema), full visual fields to confrontation, but otherwise appeared well.

If you're in medical school, make your diagnosis now...

During my presentation I state that idiopathic intracranial hypertension is at the top of my differential, but that a mass lesion should be ruled out. I state that papilledema merits an MRI but that ultimately a lumbar puncture should be performed. My attending smiles at me, pats my hand and says, "please don't be offended if I disagree with you, that's a pretty rare thing to find."

We go in together to see patient X. My attending examines her and begins counseling her. Guess what turns out to be at the top of her differential? Guess what test she wants first? Yup. I may have given myself a mental pat on the back.

you know you're in medicine when #253

You're watching a television show and during a scene in which a character is getting blood drawn you look at the syringe and remark "that's not what blood looks like."

When I grow up...

A big focus in life at the moment is answering the question: What kind of doctor do I want to be? Unfortunately for me, I am currently undecided. Here's where I am:

Internal Medicine (likely fellowship in cardiology or critical care)

Pro: Some patient continuity, variety, acute care, flexible lifestyle

Con: Not heavily procedural unless I go into the cath lab

Total time: 3 years residency + 3 years fellowship

General Surgery (likely critical care fellowship)

Pro: Very procedural, the OR is fun, prestige, variety, some patient continuity

Con: Not sure I love GI problems, tough lifestyle, required lab year

Total time: 7 years residency, with fellowship as one of my research years

Pediatrics (likely fellowship in cardiology or critical care)

Pro: love the patient population, patient continuity, flexible lifestyle

Con: not procedural (again, unless cath lab), limited places to practice

Total time: 3 years residency + 3 years fellowship

I've ruled out anesthesiology for lack of patient continuity. Plus, if I'm going to be in the OR, it's going to be my OR. I would likely match in any of these, though surgery would be toughest. Current plan: subi in each, await my surgery grade and see where we stand.

ps note the M4 schedule has been posted on the sidebar, for those who are curious.

Overdue Update

I apologise for my absence. I was on rotation in downtown Detroit and the temporary crash-pad did not have internet (?!). I was on neurology, which is not at the top of my super-interesting-material list, but I did get to spend two weeks in the neuro-ICU and I do so love any kind of ICU. Bring me your super-sick, your actively dying and I will go to work with enthusiasm and diligence.

One of the wonderful things about this new hospital was the white chocolate macadamia cookies. And the Monday schwarma lunches. Yummy. Also interesting was editing my fellow's notes for proper English grammar and spelling (yes, I was called upon for spelling).

There was one very sad case: a patient who had a stroke at the young age of 41. We don't know why. He's now densely hemiplegic (can't move half of his body) and non-verbal. While under our care his wife found out she's pregnant. She's going to have a new baby and a husband in inpatient rehab who also needs her care. While rounding each morning he would start crying; he is cognitively intact and aware of his prognosis: he will likely not get much movement back.

In personal life news (yes, neurology is one of the rotations in which a life is possible), I've taken up P90X, which is quite challenging, but awesome. I finally had a good night out dancing, which I sorely needed. Sometimes there's just nothing like a cocktail and a good song to dance too. I even made some friends in Detroit, so hopefully I'll spend some more time exploring the city. Oh, and I signed up for motorcycle classes... shhh... don't tell my parents. It's going to be awesome when I visit them in May and hop on dad's Ducati! I'm working on signing up for tennis clinic, but it might be full. Boo.

Tomorrow morning is the beginning of Family Medicine... in Toledo. Also, the ramp up for studying for Step 2 (the second board exam, scheduled for June 2nd). Nevertheless, weekends off for another month so hopefully I'll be able to continue this whole "balance" thing.

I feel dirty

I am on rotation at another hospital at the moment and one of our lecturers failed to show. Instead, I got to bond with some of my fellow students (for whom this hospital is home). One of them had a great horror story...

She was evaluating a patient in the ER who came in with priapism (a prolonged erection). Draining the organ was attempted, with no success. The student's attending then told her to "milk it." After some hesitation, she did as she was told. Another attending came by and asked her what on earth she was doing?! Turns out the first attending had been joking. The patient went on to surgery.

take it where you find it

Is it sad that I feel validated when I correctly diagnose tv characters before the tv doctors?

Stating the obvious

According to my textbook, "the basic principles of hepatic resection are complete removal of the lesion without patient death."

Don't want to set the bar too high there...

MIS: the last surgery

Ok, so it was technically the second to last surgery, but the true last one wasn't nearly as unique.

The picture is not my patient, but the operation was the same: repair of a rather large primary umbilical hernia. He literally had a basketball-sized hernia filled with bowel and omentum hanging off of a 8cm x 8cm fascial defect. We managed to reduce the hernia completely, placed some synthetic mesh to bridge the defect, covered it with some muscle flaps, then closed fascia, deep dermis and skin. For those of you up on your hernia repairs, he did not require separation of parts to achieve repair nor did he necessitate a full laparotomy. We only extended our incision 2 inches above the hernia sack (the defect in the picture must be larger since his sack extends to the xiphoid). We did remove quite a bit of skin, as you can imagine.

The operation was complicated by a difficult foley placement. I thought it was just my technical error... but I was vindicated when my chief couldn't pass the catheter either and we had to call urology. They managed a foley with the assistance of a flexible scope, which revealed a significant stricture in the urethra.

In slightly less medical terms: a hernia is a weakness or hole in one of the connective tissue layers separating two compartments in your body. In this case, the hole was in the abdominal wall where your belly button is. It was about 8cm in diameter. The man's intestines had crept out of the hole and were right below his skin in the big ball hanging off of his belly. We cut open the skin, pushed his intestines back into his belly and put some mesh over the hole to prevent his intestines from getting out again. We then pulled his abdominal muscles over the mesh to strengthen the repair. Sometimes when we pull the muscles, they don't close properly because they can't reach each other. If that's the case, we cut them free from other muscles on your sides (separation of parts) so that they can move more centrally and cover the hole. Since the hernia stretched the skin, we cut off some of the extra skin and stapled the incision closed.

Rule of Threes: Music

Three recent albums you should already own:

1. Mumford and Sons - Sigh No More

2. The Black Keys - Brothers

3. Adele - 21

Great line from #2: "I wanted love/but not for myself/but for the girl/so she could love herself."

Three songs with attitude, on heavy rotation:

1. When I Get you Alone - Glee Cast version

2. Forget You - Cee Lo Green

3. Feel Good Drag - Anberlin

Great line from #1 "baby girl, you da shit/that makes you my equivalent."

Three songs recently rediscovered:

1. Tangled Up in Blue - Bob Dylan

2. Crush on Everyone - Jonah Matranga

3. She's not There - The Zombies

Great line from #2 "if you like large intestines/please let me find out."

Three songs I deny are on my Ipod:

1. Represent, Cuba - Studio Sound Ensemble

2. Tonight (I'm loving you) - Enrique Inglesias

3. Haunted - Taylor Swift

Dumbest line from #2: "If I never lied then/baby you'd be the truth."

Fabulous gift

This was given to me today by a friend. It's a plate from Gray's anatomy (the book, not the tv show) with the cardiac anatomy labeled in latin. I absolutely love it.

Inguinal hernia

On Friday I assisted a laparoscopic bilateral inguinal hernia repair. For those of you uncertain where the inguinal area is, feel your hip bones at the bottom of your stomach. Draw a line from each hipbone to where your pubic hair starts. That's roughly the location of your inguinal ligament.

The surgery provided the best view of that anatomy of the lower anterior abdominal wall I have seen to date. Better than anatomy lab without question. I can't find a phenomenal photo of it, but this one isn't bad. There is a normal weak point in the abdominal wall in that region, called Hesselbach's triangle (the HT in the picture). The vessel that borders it is called the inferior epigastric (not labeled) and a hernia medial (in HT) is called a direct inguinal hernia whereas a hernia lateral to the vessel is called indirect (through the internal inguinal ring, labeled IIR in the picture). Two important anatomic regions lie near Hesselbach's triangle, making the surgery technically quite challenging. My attending affectionally refers to these as the triangle of doom (inferior, where the femoral vessels run) and the triangle of pain (lateral, where the genitofemoral nerve runs). During the surgery he would constantly yell out which triangle we were near when our instruments got too close (which was often, it's a tiny space). "Watch out for DOOM!" "Beware PAIN!"

It was a quick, interesting case to observe; a good start to the morning. It was followed by (yet another) anterior abdominal wall reconstrution.

Professionalism

We has a small group lecture on Friday to discuss professionalism. Our facilitator was supposed to have us discuss what professionalism means to us and how we think we learn it, but instead the conversation became a reflection on the tenor of the interactions we have witnessed over the last year in the hospital. We all agreed that by-and-large the demeanor displayed towards patients was very professional. Not always warm and fuzzy, but at a minimum, respectful. The few occasions we witnessed something less were generally in the context of extreme burn out.

What was more interesting is that we witness a lot of unprofessional interaction between medical professionals. The doctor-nurse relationship has been beaten to death in many forums, but it also exists between consulting and primary teams, between different specialties and between levels in the hierarchy. In particular, medical students can be the target of unprofessional, disrespectful behavior; most commonly from non-physicians on the care team. There is something about wearing a short white coat instead of a long one that signals to nurses and scrub techs that it's ok to abuse you or ignore you at will. Maybe it's because in a few months when we graduate we will be their bosses. Maybe it's because we have zero power to retaliate. Maybe it's because we're new and young. Whatever it is, we have all experienced it.

In the end, having a collective bitch session was very therapeutic. We are at a stage in training in which we have no autonomy, no choices, long hours and constant evaluation. Being able to complain to others who understand and don't recoil with a look of disgust at our temporary lack of compassion and empathy was very freeing. And the truth is, everyone else in the world complains about their job, their coworkers and their customers at times. Is it so surprising that we, as (future) physicians, would need to as well?

Vascular: the final surgery

My last day on the vascular surgery service was spent in the OR on an exceptionally engrossing case. It was a thoracic aorta to celiac/SMA bypass. Basically, we anastamose (attach) a bifurcated graft (tube that splits in two) proximally to the thoracic aorta (above the diaphragm) and distally to the celiac trunk and the superior mesenteric arteries (one leg of the graft to each artery. This means it's attached once to the aorta, splits, and then each leg attaches to one of the arteries). The patient was suffering from mesenteric ischemia (bowel that wasn't getting enough oxygen) due to atherosclerosis. Two of the three arteries supplying the gut were completly occluded, so those are the two we bypassed, improving blood flow to the gut and hopefully reduing his pain.

The attending was Dr. C, an eccentric Spaniard who is both an exceptional technical surgeon and an enthusiastic teacher. He would step back every 10 minutes or so during the dissection to describe the planes of anatomy he was crossing, ask a few reasonable questions and then have everyone stick their hand in and feel for key structures. The incision was along the ninth rib space in the retroperitoneum, just below the diaphragm. We dissected through the diaphragm to access the thoracic aorta; then through the pleural space while strategically collapsing the lung. This provided a beautiful view of the heart contracting, which is really quite captivating. This lateral incision also allowed us to leave the kidney alone, though we did have to mobilze the pancreas. Once the graft had been sewn in and we were closing, we reinflated the lung. It was pretty nifty to see the lung inflating and deflating with each breath while we closed the diaphragm. Dr. C let me close the skin, which involved no small number of subcuticular stitches (yay).

In the end, I really enjoyed my month on vascular. It almost makes me think I would enjoy being a surgeon, so we'll have to see how MIS goes. I wonder if the novelty of being inside someone would wear off and it would become tedious? You don't really follow your patients and you take care of such a compartmentalized portion of their health. On the other hand, you get to operate. The trouble with liking everything is that it becomes awfully hard to choose.

180 degrees

I had an amazing day on surgery, which is unexpected but welcome. There was a blizzard overnight, the new interns were starting and I was on call so I was geared up for a long, rough day. Instead...

1. I presented patients on rounds and the fellow liked my plans

2. I pulled drains and changed dressings before the OR (it's fun to do things)

3. I did the electrocautery to open the patient's groin (in the OR)

4. I got to close the groin alone

5. The uptight fellow looked at my closure and said "you've got skills."

6. I actually had a 45 minute lunch

7. We did a helpful teaching session on trauma and I managed to not interrupt

8. I was sent to consult a patient because I knew more about the procedure than the intern

9. The uptight fellow had me do the entire add-on I&D while she supervised

10. The uptight fellow gave me unexpectedly positive feedback

11. I was paged while in the OR by another attending

12. I was sent home at 8pm on a call night

I should probably stop calling her the uptight fellow since I actually sort of like her now. Since I'm less scared and we've both gotten used to each other, I feel like I can relate to her somewhat. I feel like I've seen a little of her human/personal side rather than just her all-business/work side.

Medical funfact #249

We use protamine sulfate to reverse the effects of the blood thinner heparin. One potential side effect exists for males who have undergone vasectomy...

Protamine is made from salmon sperm. Usually, the (human) testicles reside across a special barrier from the rest of the body, much like the brain. If this barrier was damaged during a vasectomy, some of the protamine could cross it. The human immune system would then mount an allergic reaction to the non-human sperm proteins.

And for the beauty pageant contestants out there: no, protamine cannot get you pregnant.

Sunday call

There is nothing quite like a morning amputation to make your day feel productive. By lunchtime you have already rounded on all the patients, redressed the wounds, updated the orders, written progress notes and removed a person's limb. Call it macabre, but that's a lot of to-do list items checked off.

Amputations feel so satisfying because you can physically see the work (unlike a stent or graft where all the work is interior). They are also extremely quick surgeries; you bove through the skin/muscle, saw through the bone, clean up the edges and sew a skin flap. Done and done. From induction to reversal, taking off this guy's forefoot took one hour. And yes, they let me cut through some bone. There was a lot more spatter than with the above-the-knee I did last week. This time I had blood spray on my goggles and mask (cool).

The picture is an x-ray s/p (after) a transmetatarsal amputation. People lose their forefoot and have special shoe inserts that help them with ambulation.

There is another guy on the floor at the moment who had a bypass graft done earlier this week. It's a high risk graft, which means there is a strong likelihood the graft will clot off. More of a when than if. To extend the life of the graft we put the patients on coumadin. Well, this guy really doesn't want to take it in case it causes some nausea. SERIOUSLY? How is this a decision? Take the coumadin +/- a anti-emetic and keep the leg for a few years vs. don't take coumadin and lose the leg in weeks. He has to think about this?

Tidbits

1. Standing in the OR holding a freshly amputated leg (above the knee) and putting it in the disposal bag. When you take something off the table, you have to call out. Examples include: knife down, needle back, etc. Handing off the leg, I stated "one partially used limb for pathology."

2. Putting stitches into a femoral artery graft. They have to be perfect because you don't want the patient bleeding from the graft-artery junction (anastamosis). The attending let me throw the last 4 to close the anastamosis. The needle we use is less than a millimeter thick and 1cm long. We took the clamp off and... my sutures held!

3. A patient on the thoracic service was bleeding through his dressings after having an emergent bilateral fasciotomy (two big incisions in each leg, left open) earlier that morning. The interns were busy dealing with a patient having a heart attack so they sent me down to do the consult. The fellow and attending agreed with my plan and had me present to the primary team. The nurse didn't want to touch the dressings so I redid the surgical bandages (more complicated than just some gauze), stitched his central lines in place, then answered the wife's questions. Basically, I acted as the consulting resident from vascular (quite a promotion).

4. Putting a Foley in a man with a penis that is permanently fibrosed in the erect position.

bad days

I'm coming to the conclusion that when choosing a specialty, you need to choose the one where even the bad days are somewhat fun. I don't mean bad as in the previous post where you're emotionally drained; I mean bad as in technically the sh*t is hitting the fan. An example of one of these painful days...

I got to the unit at 5:30am for pre-rounds, as usual. I checked in on my patients and took down the dressings, as usual. We rounded as a team and I re-dressed the wounds, as usual. There was no morning conference so I headed down to the OR early to put in the patient's Foley and watch anesthesia place the central lines. The planned surgery was an open (cut the abdomen open, rather than inserting a catheter though the vessels) abdominal aortic aneurysm repair. It should take 4-5 hours. I was scrubbing with the uptight fellow and one of the old Spaniards.

The case began and he was a little wetter (oozing blood) than expected, but otherwise the dissection to the retroperitoneum was uneventful. We were able to clamp infra-renally (good) and got proximal and distal control of the arteries near our anastamosis sites. We began grafting to the aorta, but the clamp appeared through the posterior wall. This means the aorta had torn, so we had to reclamp, higher, and get control of the bleeding. We managed to get the graft on, but the patient was still bleeding. We discovered the aorta had torn proximal to the clamp. We attempted to mobilize the aorta and sew the tear closed, but it continued extending. It look 3-4 hours and a supra-renal clamp to repair the tear. We turned our attention to the iliac anastamoses, and one of these also proved problematic with excess bleeding. We finally closed the belly to find he had stopped urinating and had stooled all over the OR table. At this point he had lost just over 13L of blood.

We did dopplers of his feet to check for pulses and found one limb to have absent pulses and pallor. We prepped for a thrombectomy, to extract the presumed clot released when we came off the aortic clamp. Once in his groin, we found very calcified arteries and insufficient forward flow to float a catheter down the leg. We immediately converted to a femoral to femoral bypass graft. We opened the other groin and reheparinised him. The bypass was completed uneventfully and his groins were closed. At this point, he had another 2L of blood loss.

The whole operation took 14 hours (I was allowed to leave at hour 12) and ended up being really rough on his kidneys (suprarenal clamp) and having a very long aortic clamp time (no fresh blood to the legs -> tissue loss -> also bad for kidneys). He's stable (for now) in the ICU. The point (long-winded, yes) is that this was a tough case where everything was going wrong. This is a painful surgery, even for a surgeon. In fact, the attending that started the case was not the one who finished it. If you can still find some fun in this kind of day, then maybe the OR is the place for you. Me, well, I did not find so much fun in this. But there are rough days in the ICU I get some rush from. Where the fight is energizing as well as draining. So I don't think I'm a future surgeon, but I think I earned some respect from them for standing in that OR for 12 hours with no food/water/peeing/sitting.

We all fall down

Well, I suspected it would happen, but surgery broke me. On Friday night I was reduce to tears. Or more accurately, collapsed sobbing on my bedroom floor. It was, in all honesty, a pathetic sight and a definite low-point. How did this happen? Well... Friday actually started out quite well. Rounds went relatively smoothly since we had the relaxed fellow. Then it was off to clinic with the nice attending. The first two patients didn't show so I was able to grab a coffee and tend to some email. I managed to see six patients and write their notes before leaving for seminar, prompting Dr. E to tell me I was "ready to be a fourth year." So yeah, the day started out fairly well. Seminar should have been a hint. It was about our future, a topic that always give me a little spasm of fear: will I be able to match to geography I like given my Step 1 score? Am I going to get stuck doing primary care in Idaho? A classmate approached me during seminar to tell me that the uptight fellow had scrubbed on some cases at the VA with him and spent the time in the OR asking my fellow student pointed questions about ME (unprofessional!). He couldn't say anything nice (what?) so he lied and said he had never been on service with me (thanks). I got back to the conference room after seminar in time for afternoon rounds. When the other students on vascular got back they made it clear I shouldn't have left without them (they left without me last week). Off to teaching rounds with the over-enthusiastic attending who pimped JUST ME on surgical abdomens, but felt the need to stop halfway through to tell the whole room that I was defensive and arrogant and should get that under control (unprofessional!). After teaching rounds the two medical students on vascular cornered me to have a frank talk about how I interrupt too much. I then took some staples out of a woman's abdominal wound and was allowed to leave. I got out of the hospital into the freezing air and tears started sprouting. Trouble is, they started freezing in my eyelashes as I walked. Yes, I froze my eyes shut crying on the walk home.

So let's reflect: yes, the "constructive" criticism I received is grounded in truth. My board scores are my fault. I am defensive, but not out of arrogance. I hate getting things wrong because I'm terrified. I probably do interrupt too much, but could that conversation possibly have waited until the next day given they had just watched me get humiliated by an attending? Not to mention that I have not committed the cardinal sins of throwing another student under the bus or claiming all the good surgeries?

End result: I don't have skin thick enough to be a surgeon. Nor do I want to. I do take it personally when people criticize me; because I care. I care that I'm good at this and that I am respected. I don't want to become the kind of person who can humiliate another person in public just because they can't talk back for fear of their grade. It does not help my learning. Being a good teacher is about motivating and empowering, not belittling and intimidating. Surgeons seem to confuse fear with respect.

A clue, sherlock?

The big decision: internal medicine vs. pediatrics.

While on call on Friday I was with my team (vascular surgery, at the moment) on evening rounds checking on patients before we more or less leave them alone for the night. One of our patients was a young boy, so we had to trek over to the children's hospital to check on him. On entering the pediatric intensive care unit, I got this little stomach flip-flop. That little bubble of abdominal excitement you get when you're about to open a present or buckle yourself into the rollercoaster with 7 loop-de-loops. I wonder if that fleeting visceral excitement is a signal from my subconscious telling me to be a pediatrician?

Surgery begins

On Monday I began my vascular surgery month. It's now Wednesday night and I have already worked 31.25 hours. They have us track because we aren't supposed to go over 80 in a week. Legally we can, but they don't want us to have it worse than the interns. How generous. Not that they would actually send us home if we hit 80; they just want to know.

Regardless, I spent day 1 in lectures and the simulation center; days 2 and 3 involved rounding and then hitting the OR. The OR is an interesting mix of incredibly cool and unbelievably boring. There are moments when you are helping, being quizzed (or taught) or watching something insane. Those are the cool parts. Then there are long stretches of time when you are largely ignored, uninvolved and staring obliquely at something which is probably an organ or blood vessel. You try your best to stay out of the way, remain sterile and ignore the aching in your back and feet. And the fact that you are hungry. And need to pee. Those would be the boring bits. Thankfully, the vascular attendings are somewhat more enthusiastic about teaching than reputation would have you believe and they like playing music and cracking jokes in the OR. This helps the time move more quickly.

In fact, one of the patients today was under sedation (rather than anesthesia and thus is partially awake) and requested Barry White be played. We complied and he sang along! This while we were debriding his horrendous foot ulcer and stenting open his right leg arteries by sending a catheter down his left arm. Bonus, one of the nurses showed me where she keeps her stash of peanutbutter Dove chocolates... score!

them apples!

Is it just me, or have apples become ginormous?

Hace calor. Hace sol.

I have returned from a two week trip to Argentina. Amazingly, this is the only true vacation I get between May 2010-Dec 2011. Yay medical school. Anyway, I returned from a trip to El Calafate and Buenos Aires. Unfortunately time did not allow me to see Torres Del Pine and circumstances prevented a side trip to Colonia, Uruguay, so those will have to be accomplished in a subsequent trip.

In El Calafate we hiked the Perito Moreno glacier; first an hour along the lateral moraine, then four hours on the accumulation zone (complete with crampons) before hiking back out along the lateral moraine again. It's impossible to capture the scale of the glacier with photographs. The weather was fantastic; I did the second half of the hike in just a long-sleeved t-shirt.

We also hopped onto some horses to see the surrounding countryside, which is practically an iridescent shade of green. It's complete with wild llamas and plenty of space for a good gallop or a cozy lunch of steak, onions, wine and havanas.

Back in Buenos Aires we did a little going out, a little cultural enrichment and a lot of reading and relaxing. And eating. There is a lot of great food (especially ice cream), but interestingly, no peanutbutter to be found. Anywhere. There might have been a little shopping in there too.

Going out in Argentina is a bit crazy because, in general, dinner is between 9-11pm. No one arrives at the bars or clubs until 2-2:30am and then people stay out until sunrise. Needless to say, that's not my usual schedule so it took a little adjusting too. As did coming back (to surgery and 5:15am pre-rounds). We went to a local, unmarked bar to shoot some pool, a swanky foreign bar, spent a night learning to tango and hit up a hip-hop club, complete with break dancing and dance crews.

Overall, I was surprised by how European the city is and how good the English is (although a friend who was also there said he had more trouble with the level of English). It's definitely a place I would enjoy returning too and there are plenty of stunning landmarks I missed: Mendoza (wine country), Iguazu Falls (natural wonder) and the previously mentioned Torres Del Pine. It also reinforced the fact that I absolutely must learn Spanish. It is an extremely useful second language in medicine and in travel.