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.