Dr. V on maternal mortality:
Once upon a time I did a post composed of live blogging from the ER. I thought I would replicate the concept tonight by giving you an idea of what a transplant case looks like for me.
11:07 - consent is obtained and I receive an email. I am now aware that a donor liver is expected to arrive for a patient and the surgery should occur sometime today.
17:48 - I find out the donor liver is not expected to arrive until after 10pm, that means an overnight surgery is likely.
21:11 - I call the main OR desk and they indicate a lines-in time of 11:30pm. That means the incision won't happen before 00:30am.
23:50 - I arrive at the hospital to change into clean scrubs, prep some dry ice for samples and start the paperwork.
00:18 - I head down to the OR to check on the progress. They are just finishing the echo and still have to place the radial line.
00:37 - Incision. I draw two purple tops and collect 10cc of urine. I leave the OR and head to the lab to centrifuge the samples and put them on dry ice.
01:26 - Back in the OR to observe
02:51 - Anhepatic phase begins. This is when the patient is no longer connected to his old liver and not yet connected to the new one. I draw samples and put them on ice to process later.
03:29 - Reperfusion. This is when the new liver is connected and circulation through the liver is restored. All the preservatives and biochemical waste from the new liver cause the patients heart to struggle briefly. When well-managed and with a little luck this can be short-lived and uneventful. Tonight, reperfusion goes smoothly.
03:59 - I draw samples and bring them and the pre-reperfusion samples up to the lab to process. Sometimes I stay in the OR until close, but tonight I'm hoping to catch a few hours sleep before class. If the close is within two hours of my shift ending, I will be able to draw the closing samples and leave. If not, I will have to stay until 2 hours post-op.
04:40 - The surgeons have closed, the operation is complete. This was a very short surgery, which is good for the patient, but bad for me. I now have to stay until 6:40 to do the 2 hour post-op samples.
04:50 - Follow the patient up to the SICU to get immediate post-op samples. Run back to the lab to finish processing samples already collected.
05:30 - Email an update about the surgery and schedule for post-operative draws through POD4 to the research group.
06:30 - Head over to the SICU to check in with the nurse and get the 2 hour draw.
06:45 - Head back to the lab to leave the samples on ice (the girl coming in at 7 will process it), head home to catch a three hour nap before class at 11.
Last night was the performance of the swing dance we've been working on for the last few months. We all landed our big breakout moves, which was awesome! Proof that med students do something other than study ;)
I thought it would be interesting to total the number of exams I will take prior to my first clerkship in medical school.
This is a photo of me getting dressed for new years this year. It was a low-key affair with low expectations so it turned out to be an okay night. I wasn't quite back to myself -I'm still not- having just been traveling internationally. I always get a bit brooding when I return home. I don't like giving up the freedom of traveling - life is a bit too tied down and restricting for my taste. I wonder if I should have taken more time off - a whole year of traveling instead of just a few months? I also miss the person I am when I'm not here - I'm more confident, easygoing, in-the-present when I'm away.
My much-anticipated new shoes came - limited edition pinstripe Jack Purcells. I love them. Super preppy with a twist. So perfect. They took their inaugural walk to get me to IV clinic and back.
IV clinic is where the emergency department docs teach us how to place IVs and subsequently give us equipment to practice on each other. My friend J and I stuck each other three times. It turns out placing IVs in the hand is both more difficult and more painful than in the arm.
I watched the premiere of Scrubs season 9 and was disappointed. What the hell were all the first year medical students doing on rounds, in scrubs and working with patients? Your first two years (until you take and pass the boards) you are lucky if you shadow rounds - you are definitely not let loose in the hospital. Not to mention you would definitely not have a class called internal medicine before you've completed something as basic as anatomy. C'mon writers. Seriously.
Speaking of boards, I've turned in my registration for mine. I'm aiming for April 26... USMLE step 1 is officially on my radar.
I haven't been in the OR since Oct 14th, but I'm on call this Thurs-Sun. Here's hoping for a liver. Except maybe not Sat night (day is fine) because I have a date and I would kinda like to make it. Even if I have to show up with a pager and track marks (from IV clinic). Actually, Sat would be a good time to get my autopsy requirement out of the way. So here's hoping for a dead body and a life-saving liver, all in one weekend.
While gchatting (ostensibly studying neurology) a friend sent me a news story (from the science section?!) detailing how much skin a woman should show to maximize attractiveness to nearby men.
Methods: This was an observational study in which the authors used percentages of the body to determine the amount of exposed skin. Each arm was 10%, each leg 15% and the torso 50%. They they counted how many times each woman was approached. Neither the men or the women knew they were being studied.
Results: Women showing more or less than 40% exposed skin were approached less frequently.
Conclusion: Women showing less than 40% sent "prude" signals and women showing more sent "whore, adulteress" signals.
My immediate reaction was not "what a stupid thing to study" or "how can they claim to know what the men were thinking" or even "how does the methodology account for the possibility that the 40% women just happened to be the hottest regardless of clothing".
No, my reaction was: they got the body percentages wrong! Commonly used body surface area percentages for estimating burn injury are shown in the picture.
picture from UofM burn website: http://www.traumaburn.org/referring/fluid.shtml
Thanks to medical school I now know:
- The annoying twitching that my left deltoid has been doing all day is called a fasciculation.
- My myopia will likely mean a later onset of presbyopia (compared to non-myopes).
- When I was a child I had a form of parasomnia (I sleep-talked; c'mon, who's surprised?).
- Neurologists like disorders with either 1) long names or 2) eponyms 3) both for the same syndrome (ex. acute demylinating polyradiculoneuropathy aka Guillian-Barre)
- Ophthalmologists also like long names, but prefer they end in "-ia" (ex. internuclear opthalmoplegia)
- If you eat contaminated pork, you can get pork tapeworm (T. solium), but if you eat a carrot contaminated by someone with pork tapeworm you get neurocysticercosis so cook those carrots good (see picture above).
- Laser Assisted Subepithelial Keratomileusis (LASEK) surgery involves shearing a flap into your cornea, while you are awake (with analgesic eye drops, picture).
- Anesthesia is technically only central nervous system depression. When you are put under you also get neuromuscular blockade (paralysis), analgesia (pain control) and amnesia (no memories).
- A symptom of hepatic (liver) failure or renal (kidney) failure is asterixis (characteristic hand flapping). It is likely accompanied by encephalopathy (altered mental status). Oh, and you're in danger of dying, soon.
Recent quotes from lecture:
"Our country handles schizoid personalities very well. That's why we have software engineers, pathologists and Montana." -Dr. J
"Biopsying an aneurysm is not a successful procedure." -Dr. G
"If someone's head is cut completely off, that's not an emergency - that's a tragedy." - Dr. G
Medicine is full of big words with very specific meanings. Here is a fun paragraph from today:
Internuclear ophthalmoplegia (INO) is indicative of a particular opthalmoparesis. It is a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction. When the partner eye is abducted, it diverges from the affected eye. This produces horizontal diplopia. During extreme abduction, compensatory nystagmus can be seen in the partner eye. Convergence is generally preserved.
You realise you washed suture with your white coat.
AND you're excited it's still in tact so you can practice.
I felt a certain pressure to match last year's pumpkin. I fear I did not manage it.
Last year:
This year:
Time I got paged this morning: 5am
Hours of sleep I got: 3.25
Time I waited for my patient to pee: 8hr 37min
# 12oz coffees I drank in that time: 2
# times I peed in that time: 3
Interesting fact: Identical twin transplant recipients do not need immunosuppression.
Another interesting fact: The first dialysis machine was made out of sausage casings and a bathtub. (picture)
Health disparities fact: While ethnicity is not a match criteria for organ transplant, blood type is. Caucasians (who form the majority of donors) tend to be O & A blood types. African Americans, who have the highest need (for kidneys) have a much higher incidence of type B blood. (source: http://www.bloodbook.com/world-abo.html)
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.
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.
(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.
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.
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"
