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.