Anguis et Columba

Back on trauma surgery

2009-03-06T19:10:00.000-08:00

The only place where your patient's boyfriend is arrested in the hospital for assaulting your patient over a potato chip--and the only reason your patient is not also arrested is because the police couldn't deal with the four inches of undulating bowel protruding from her abdomen pouring out stool.

Kudos

2009-02-12T17:48:00.000-08:00

This morning we had a ninety year old woman who had newly diagnosed breast cancer. Rather than going through the risk of general anesthesia, we performed a lumpectomy under local anesthesia while she was wide awake, not getting so much as a drop of ativan. Immediately after, she went to the pharmacy to pick up some painkillers, then drove herself home (waiting until she got there to take anything, since one can't drive if taking narcotics). She didn't have anyone with her because she didn't tell her son and daughter she was having the surgery until last night so that they wouldn't be able to miss work for her. She takes care of her demented husband at home, so had to be back quickly.

Last night, one of my post-op patients, rather than waiting 5 minutes for the nurse to page me for more pain medication, called a rapid response from her room. What she thought it would accomplish I don't know, since it's composed of nurses who can't give narcotics without an order anyway. Then she called the operator and tried to bully her into calling my attending at home. Quite a contrast.

Back

2009-02-07T10:32:00.001-08:00

This month I'm again at one of the local community hospitals. While in a lot of ways more relaxing than the academic hospital, we only have two residents this month so we've been pretty busy. I started out on Sunday, thinking that I could round early, take care of a couple minor issues, then go to church for the first time in a month (we take home call there, so don't have to stay in the hospital if nothing's going on--we just come back if there's a new patient or one of the current patients crashes). That dream ended when I was paged at 5:30 AM by the intern who had been on call Saturday night, to let me know that one of the patients had to be transferred to the ICU overnight, and was doing very poorly. Additionally, a nurse just called him to let him know that one of the vascular surgery patients had a cold and pulseless foot (which, if true, would be a surgical emergency).

So, hopes of a quiet Sunday crashing, I went in to the hospital, stopping at security to get my ID badge and keys, that should have been left there Friday. Only none of the three security guards could find them. I got them to give me a student ID though, so I had access everywhere. I then proceeded to the ICU, first stopping to see the "cold, pulseless foot". It was actually quite warm, and I could palpate a posterior tibialis pulse though not a dorsalis pedis. I looked through his chart, and there was no mention of anyone ever being able to palpate a dorsalis pedis, so I was not terribly worried. I went to see the next patient, and found that she had been made DNR/DNI (no resuscitation or intubation if she crashed) by her family. She barely had a measurable blood pressure despite being on a high dose of vasopressors, was completely unarousable, and had dilated, nonreactive pupils. There wasn't really anything to do, but I called my senior to let her know what was going on. Then I called the family, and confirmed she was really DNR/DNI. They eventually chose to pursue only comfort care, so we stopped the vasopressors and she died within 20 minutes. It was the first time that I had to pronounce someone dead and call the family--fortunately they knew she was doing poorly, so it wasn't a shock. In between dealing with these issues, I was also trying to round on all the floor patients whom I had never met before--thankfully there weren't too many of them.

Once that was done with, we ended up having one OR case that had been added on, a pilonidal cyst excision. I got to do the procedure, which was nice. By that time it was 3:00, and I went home. Nothing else happened, so I slept most of the night.

I do have to give a little note about pager etiquette--when you page someone, you are essentially asking that person to stop whatever he or she is doing and call you back. To be courteous, you need to be at the telephone when that person does call back, and you need to wait by the telephone for a minimum of 5 minutes, in case they're doing something else and can't get to a phone. After 5 minutes, you can leave and let the clerk call you back when the person calls back. It is completely unacceptable, and actually very rude to page someone then leave the phone. I mention this, because there is one particular hospital we rotate through that every single nurse does this every time, so that when I call back seconds after being paged, I am then put on hold for five minutes waiting for her to finish whatever task she has left to go do and actually come back to the phone. It is incredibly infuriating, and essentially is telling whoever you paged that your time is worth more than theirs. Now I wait on hold for a maximum of one minute then call the secretary back and tell her to tell the nurse to re-page me when she has time to talk. It's gotten me a couple of apologies, but they continue to page and leave the phone. This doesn't happen at any other hospital I've been to, so it shouldn't be asking too much. All right, end of rant.

Kids

2008-11-15T11:10:00.001-08:00

I just finished a month of vascular surgery. I saw and smelled more foot ulcers than I ever cared to see or smell, and amputated more limbs than I cared to amputate. People, if you have diabetes, please, please take your medications. And if you have neuropathies that have taken away the sensation in your feet, you MUST check your feet EVERY day. If you smoke, stop. There are few sadder sights than a 50 year old man with both legs missing sitting in a wheelchair puffing away, especially when you realize that he'll be dead from heart disease within five years.

I'm on pediatric surgery this month--it's been quite interesting, though taking care of kids is not my cup of tea. It's by far the busiest rotation at my program, I'm on in-house call every second or third night. It is a great rotation though, with a lot of OR time. The attendings are great too. They have two fellows, and in order to give the senior fellow more operative time, they only make him take in house call about twice a month. To do this, the attendings themselves actually take in house call in his place a couple times a month. A bit intimidating for the junior resident, if as happened to me, he or she ends up on call with the chairman of the program instead of a senior resident, but I think it says a lot about their dedication to the fellows' education.

Most of the cases I've been in are pretty straightforward, lots of abscesses, appendicitis, and pyloric stenosis, but we also get all the rare cases as well, biliary atresia, gastroschisis, etc. The worst case I've seen was a trauma that came in last week--a one year old boy who came in without a pulse. He had been beaten by his aunt that evening. He didn't have any external marks, but you could tell the second he rolled in the door he wasn't going to live. We did the whole resuscitation anyway, and got his pulse back for a while, but when I shined a light in his eyes his pupils were completely blown and did not respond at all. The CT scan showed what we all knew, a huge hemorrhage in his brain. He went to the ICU and died a few hours later. What makes it worse is that the police brought his two year old sister in a few hours later after taking the aunt into custody. She had burn marks and sores all over her body, including circumferential wounds around her ankles and wrists consistent with having been tied down for a long time, and an old scar encircling her neck. We did xrays of her entire body and found several fractures that had already started healing in malalignment. She's doing well now, but still starts uncontrollably shaking every once in a while. Her aunt was her foster parent since her biological mother is mentally incompetent, even though she (the aunt) was a known child abuser. Yet the state still allowed her to keep the children. And now one of them is dead. The extended family has been in the little girl's room, and acts very concerned and worried. I've been polite to them, but not especially empathetic, because frankly I don't think any of them should even be allowed to enter the hospital.

Hmmm

2008-10-15T19:27:00.001-07:00

Scene: Me, sitting in front of patient's room in the ICU, vigorously writing admission orders and an H&P. Middle-aged nurse sitting a couple feet from me, looking over a chart.

Me (to the nurse): Excuse me, do we have a temperature on this guy?

Nurse (looking up at me with an irritated expression): (sarcastically) No, I haven't gotten one yet since I'm kind of busy admitting the patient.

Me: A'ight (medical abbreviation of all right), carry on.

Nurse (a minute later, looking at the telemetry machine): (growling angrily) He's having PVCs (premature heart beats, often caused by electrolyte imbalances)!!! I want labs!!!!!!!! Who's going to get me labs!!!!!

(Nurse stands up and stomps furiously into room, I follow)

Me: (politely) Excuse me?

Nurse: (angrily) I need labs, what labs??!!!

Me: Actually, we already know that his potassium is low. I just wrote an order for some potassium supplementation.

(Nurse angrily turns around, looks at me, opens her mouth with a snippy comment on the tip of her tongue. Suddenly she halts, and her eyes grow big).

Nurse: (pleasantly and apologetically) Oh I'm so sorry, I thought you were a medical student! Oh, I feel so bad for talking to you like that. Let me start over, I'm Laura (extends her hand). Now doctor, would you like me to give 20 or 40 milliequivalents of potassium? Oh, I'm so sorry for being so rude. I didn't notice you were wearing a long white coat!

Me: It's all right, no problem.

Medical student standing behind me with mouth hanging open: Silence

So apparently treating me like garbage would have been OK six months ago, but is unacceptable now.

Getting things done...not always easy

2008-08-16T16:26:00.000-07:00

It's been an interesting couple of weeks. Although I'm actually working the same number of hours this month as I did on trauma, I feel much more relaxed. We have been averaging 3 or 4 patients at any given time, so I have just been rounding on 1 or 2 in the morning, then going home around 3 or 4 unless I'm on call. So far nothing terrible has happened on call.

My attending for the first two weeks is very hyperactive and gets bored very easily. He also has a very direct attitude. I actually really like him, he teaches and makes rounds incredibly entertaining. The anesthesia residents, used to lower-key attendings didn't like him at first but are now coming around. The nurses want to kill him, which has made things somewhat awkward. ICU nurses, at least the ones here, are generally very good. They only take care of one or two patients at a time, so they know their patients well. They are used to taking care of very sick patients, so there isn't much that can phase them. The problem is that their comfort levels are often so high that they think they know how to take care of the patient better than anyone else, and they do all they can to get their way. Whenever one of us (residents) gives an order they disagree with, we have to come by every twenty minutes to make sure that it actually gets done, and that they don't "forget" or get "too busy" to do it. There have been several times I've asked them to do something one way, and a couple hours later I'll come back to find that they've done it the way they jolly well pleased. This makes me very irritated--I really respect ICU nurses, and they often know how things work in the ICU better than I do--if they suggest a plan different than mine, more than likely I'll defer. But doing the opposite of what I say without telling me is unacceptable (and technically illegal). There have been a couple occasions when they didn't like what one of the senior residents said, so the paged the fellow over her head, and lied about not having been able to get a hold of the resident. They are usually better when attendings give orders--the problem is, as previously mentioned, they hate my attending with a passion because he actually insists that things be done the way he orders. So their solution is to call the surgeons with questions rather than the ICU team. This leads to the surgeons' ordering things without our knowledge, which leads to bad patient care from a too many cooks in the kitchen standpoint. It has altogether been very frustrating, and puts me far too often in the position of choosing between being undermined by someone who legally and ethically must follow my order, or making an issue of it and becoming hated by the entire ward and subject to all their passive-aggressive maneuvers. So far I've let things slide. I'm not sure how much longer I'll be able to take it. Many of the older nurses don't bother with the passive-aggressive behavior, they just flat out tell us they won't do something (this is actually why they hate my attending--they've told him that a couple times and he's made them do it). I'm just getting so tired of the squinty-eyed-that's-stupid-I'm-not-going-to-say-anything-but-as-soon-as-he-leaves-I'm-doing-it-my-way facial expressions. I think I find it particularly frustrating because I have always made such an effort to treat nurses like colleagues (and despite how this post sounds, I am actually on very good terms with the nurses in the ICU--which in some ways makes it harder).

ICU

2008-08-03T15:35:00.000-07:00

I just finished trauma. I am now beginning an ICU month at the local VA hospital. I had my first call night on Friday--it wasn't nearly as bad as I was afraid it would be. All our patients were stable and I was able to deal with all the issues that arose without having to page anyone higher up.

This month is particularly intimidating for me as 1) these patients are much sicker than any patients I have dealt with before and 2) when I am on call I am the only surgery resident in house (as opposed to last month when I had a chief in the hospital with me whom I would run things by ever couple hours) which means I have to page the fellow at home if I have a question about something. On the positive side our patient census is very low (I only had three patients to worry about).

Another negative thing about this month is that it is at the VA. While I think the VA here does provide good patient care, it is, to put it delicately, a "no-frills" kind of place. For example: my main hospital has a couple decent cafeterias, one of which is open 24 hours a day. When I don't get a chance to eat until 10pm, I can still go down and get a hot meal. The VA has a cafeteria that is abysmal (yet more expensive than my main hospital's), and that closes around 4:30pm. On surgery, one doesn't eat dinner by 4:30pm. There is nowhere else to get food. You can see my dilemma. Fortunately, on Friday there was another resident who had to stay late, so I was able to drive to McDonalds and get dinner there. This will not always be an option. Continuing on the "no-frills" theme, the whole hospital just has this atmosphere that is impossible to describe. Getting logistical things done takes 3-4 unneccessary steps (it took me hours to get my computer access straightened out despite the fact that they gave me a login just over a month ago--and getting meal tickets for call nights [that I may theoretically be able to use some day] was almost impossible). All the employees from clerks to nurses have a "this is the way we do things around here and nothing short of a presidential order no matter how logical or efficient your request will make me deviate from protocol in the slightest" attitude which can really get annoying. That all being said, I'm going to learn a lot this month, which makes it worth it.

Bullets and Bones

2008-07-10T16:15:00.000-07:00

Two more call nights down, both much busier than the first. The vast majority of the time was spent doing floor work, but I also got to sew several lacerations and remove a bullet from a man's chest (learning point: when removing bullets, never touch them with a metal instrument, otherwise you can mess up forensics/ballistics).

We had a lot of really tragic traumas. One was a pedestrian struck by a car who came in intubated and unresponsive. I performed the primary and secondary survey, and actually picked up all her injuries (brain injury, rib fractures, pelvic fracture, ankle fracture) on my physical exam. I went with her to the CT scan while my senior went to the OR--we did the head CT first which showed a very large bleed between her brain and her skull that was pushing much of her brain into the other side of the skull. It was large and obvious enough that I called neurosurgery immediately without needing to talk to the radiologist or my senior first. The neurosurgeon came quickly and whisked her away to the OR for a craniotomy.

That night, I went up to one of the floors to talk to a patient with pancreatitis who was very upset that we weren't allowing him to eat. He stated adamantly that he was going to go home--I let him rant for a while, acknowledged his frustration, and then talked him into staying. I have discovered that the best way to deal with people like this is to try to agree with them as much as possible, then use their own words to change their minds. Getting defensive or arguing just makes it worse.

When I left his room, a nurse came up to me and asked if I had any new orders for an appendectomy patient--problem was, we signed the discharge orders that morning, and had assumed (fatal error) that the patient had gone home. When I expressed my surprise that the patient was still here, the nurse cheerfully explained that the patient had decided she wanted to stay another night. Uh...yeah....what with hospitals not being hotels and all, patients don't actually get to decide whether or not they stay--that is a doctor's decision. Struck speechless, I went to talk to the patient. Her mother was in the room, and told me that they hadn't wanted to leave earlier in the day because the patient was dizzy, and that the nurses had told them they could stay the night and that "the doctors" would see them in the morning. The patient then walked cheerfully out of the bathroom, and told me she was feeling much better. I explained to them that I was one of "the doctors" and that she could go home. I sent them out around 11pm. I probably should have had a gentle conversation with the nurse about this, but since I didn't know the details and I'm sure there was miscommunication from someone on my team at some point that day I didn't pursue it. Bottom line was that the patient we wanted to stay stayed, and the patient we wanted to leave left.

Call

2008-07-04T08:53:00.001-07:00

I have finished my first call night as an intern. Fortunately, it was probably also my easiest call night as an intern. I am on trauma surgery this month--an enormous service with 3 senior residents, 5 junior residents/interns, six medical students, and several NPs. And, of course, several attendings who take turns supervising the service. As July is the prime season for the knife and gun club, our patient list is very large.

On trauma call nights, there is a senior, a junior/intern, and one or two medical students in house. This month is set up so I will always be on call with the chief resident and the same senior and junior medical students. The intern has the trauma/floor pager--his job is to respond to traumas and to manage all patients on the wards (ICU patients are on a different service). The senior student carries the consult pager and staffs consults directly with the senior. The junior medical student (backed up by the senior student) has to update the patient list, and gets to go to traumas and do odd jobs that come up.

At traumas, our team trades jobs with the ER residents every week--this week ER is captain (directs the trauma) and trauma is doc right (performs the primary and secondary surveys, essentially a rapid physical exam to pick up any life-threatening injuries). My first call night we only had one trauma, and I was doc right for the first time in my life--somewhat intimidating. The trauma actually came early in the night, so after taking care of some issues (including signing my first prescription and discharging my first patient as an MD) we all went to bed around 1:00 am. I was only paged once in the middle of the night, so ended up getting about two hours of sleep. Very unusual--most of the time trauma interns are inundated with floor calls all night. We rounded the next morning, then I found out that our chief decided that today would be considered a weekend day thus all not-on-call people would get it off! Very good news, it means that I will have at least one day off every single week of the month--I was expecting not to get a day off for the first two weeks. The only thing is that I feel a little guilty--my first week of being an intern has been exceptionally easy. Oh well, I'm sure next week will make up for it.

It is very scary getting calls about patients from the nurses. All the ones I got were simple questions, but at this point in my career I am constantly questioning all my decisions. Just giving an order to give the most innocuous medication is terrifying--I order tylenol, and then envision that patient being the one person in a million who goes into rampant liver failure from it. I got a call from a nurse about a patient who had a little bit of bloody drainage around a wound. The nurse wanted to hold the patient's anticoagulant (which we were using for prophylaxis against blood clots). I didn't think we needed to hold it, but kept envisioning the patient getting his/her dose, then suddenly having a massive hemorrhage and dying from shock. I ran it by my senior (again, the nice thing about having in house residents--I would have felt really stupid paging someone at home about this, but since I saw him every couple hours I could run a list of things by him regularly) and he confirmed my initial decision. Fortunately, we have excellent seniors--I wouldn't be afraid to call any of them with stupid questions which really is the primary responsibility of interns at this point in the year.

Only in France

2008-06-29T14:48:00.001-07:00

French military

The So-Called Problem of Susan

2008-05-29T16:30:00.000-07:00

As a child reading my favorite book series, The Chronicles of Narnia, I was often saddened that Susan, the eldest sister in the Pevensie family, in the last book in the series was seemingly excluded from Aslan’s country. C.S. Lewis tells us through Peter that Susan was “no longer a friend of Narnia”, and Jill Pole summarizes her problem as “she’s interested in nothing now-a-days except nylons and lipstick and invitations”. Clearly, Lewis is condemning mindless vanity and obsession with one’s appearance and image—I was therefore fascinated to discover that this passage has raised the ire of many well-known authors such as Phillip Pullman and J.K. Rowling, who have decided that Lewis must have been condemning sexuality and maturation. Phillip Pullman writes:

Susan, like Cinderella, is undergoing a transition from one phase of her life to another. Lewis didn’t approve of that. He didn’t like women in general, or sexuality at all…He was frightened and appalled at the notion of wanting to grow up.

In a Time magazine article, J.K. Rowling says:

There comes a point where Susan, who was the older girl, is lost to Narnia because she becomes interested in lipstick. She’s become irreligious basically because she has found sex. I have a big problem with that.

This passage has even driven a science fiction author, Neil Gaiman, to write a short story about Susan set decades after The Last Battle. It is a disgusting piece of perverted drivel, so I will not provide a link to it, but its essential point is that a loving God would not kill a family and punish a girl because she liked lipstick.

While irritating, I almost find these comments amusing. J.K. Rowling actually admits to not having read the Chronicles of Narnia, and Phillip Pullman’s other quotes (google him) reveal him to be the self-blinding, God-hating fool that he is. Whether he is truly dimwitted enough to believe what he says, or he is just talking to get attention I do not know. Anyone who has actually read The Last Battle, let alone Lewis’ other writings knows that these authors’ comments are patently absurd. For instance, in The Horse and his Boy, the adult susan is described as one of the most beautiful women in the known world, and is actively being courted. Many of his other characters grow up, get married, and have children. He never portrays characters negatively because they are female, and one only has to read the chapter in That Hideous Strength in which Venus descends to earth to know his views on sexuality.

Having established that Susan’s negative portrayal is due to her becoming a self-absorbed, conceited twit rather than to her growing up, the question remains, will Susan ever enter Aslan’s country? I believe the answer is a most emphatic yes (it is important to remember that in the books Susan did not die in the train collision—at the end of the series all her family dies and enters Aslan’s country, or heaven, and she remains living on earth). Lewis himself says on the subject:

The books don’t tell us what happened to Susan. She is left alive in this world at the end, having by then turned into a rather silly, conceited young woman. But there’s plenty of time for her to mend and perhaps she will get to Aslan’s country in the end—in her own way.

This is where my theology differs from Lewis’. I don’t think there’s any doubt in the matter. I believe that the Bible is clear that God does not save a person only to have that person decide he doesn’t want to be saved. Romans 8:38-39 says:

For I am sure that neither death nor life, nor angels nor rulers, nor things present nor things to come, nor powers, nor height nor depth, nor anything else in all creation, will be able to separate us from the love of God in Christ Jesus our Lord.

I think “anything else in all creation” includes ourselves. Are we to suppose that those who have died to sin and been made new creations, those who belong to the royal priesthood, who have been “called out of darkness into His marvellous light”, who have been made “kings and priests to God” are capable of defying the God who made them such? (I Pet 2, Rev 1:6)

This is not to say that God’s children do not stray, or that they will not be punished for their errors. As Susan’s rebellion left her alone on earth while her family entered Aslan’s presence, so we can be punished temporarily for our rebellion. But nothing can separate us from God and our salvation is sure. We can infer from this that Susan, were the story to continue, would repent and eventually join her siblings in Aslan’s bliss. Though when Lewis was alive he may have disagreed with my reasoning, I think he would have reached the same conclusion. After all, he is the one who wrote, “Once a king or queen of Narnia, always a king or queen.”

Woohoo!

2008-05-18T18:03:00.001-07:00

It's official...I'm a doctor:)

Regalia

2008-05-02T11:56:00.000-07:00

I got my robe, hood, and tam yesterday. A lot of my friends complain about having to wear them for graduation, but it's actually something that I really appreciate. I've found that the further along I get the stupider I feel and the more I realize I don't know, and I think going through the traditional ceremony in regalia that has been around since the 1100s is a nice reminder that we have actually learned and achieved something over the past several years. I did not realize however how much detail goes into the costume. As per this link from the American Council on Education, there are strict guidelines as to which graduates get to wear what; everything from the color of the panels on the robe to the fabric of the hat, from the length, width, and design of the hood to the shape of the sleeves, depend on what degree the graduate is receiving and what field the degree is in. I can see how regalia has the potential to become nothing more than vanity, particularly centuries ago when when it was worn every day at universities, but I think it's appropriate for a day.

Countdown

2008-04-29T14:10:00.000-07:00

The lack of posting has been due to two factors, 1) my internet's been down, and 2) I'm on radiology this month and thus have nothing to post about anyway. It's been a very restful month, and will only be surpassed by the first couple weeks of May during which time I will be on my "preparing for internship" rotation which is essentially just three hours of lecture a day. I have a countdown to graduation on my computer, and I am getting dangerously close to being a real doctor.

Happy Easter

2008-03-23T11:42:00.001-07:00

Kristos Anesti! He is risen!

Fact and Fiction

2008-03-23T11:04:00.000-07:00

It's been an interesting weekend. I got a patient on Saturday who came in with "10/10" crushing chest pain after shovelling snow that morning. In the ER he was started on a nitroglycerin drip and given morphine which brought the pain down somewhat. The ER's story was that he had a heart attack 12 years ago that required stenting, and was due for another catheterization (a means of looking at the coronary arteries) next week. A scary story, very suggestive of a serious problem, probably another heart attack. Fortunately, I looked at his records before seeing him.

I went down to the ER and got his story. He said he had the heart attack in a different city but did not remember the hospital. He had another catheterization at my hospital 7 years ago, but said he had not had any further work-up since. I asked specifically if he was sure, and he again confirmed his story. The problem was that the records I had seen said that he had had several catheterizations, all at different hospitals, in the last five years. The last one was 5 months ago and was completely normal. Also in his records was a history of Munchausen syndrome. However, he was so serious, I considered temporarily that the resident who dictated his last discharge summary had been mistaken. So, I called the other hospital and had the records faxed over--the previous resident had been correct. The patient was flat out lying to my face. Not only had his arteries been healthy, but there was no note of the cardiologist having seen any stents--was he lying about his previous heart attack as well? Even given this, we still had to admit him--boys who cry wolf can still really be attacked by wolves. We admitted him and checked enzymes and EKGs multiple times throughout the night. All were negative. He repeatedly asked for morphine. We refused, and he left against medical advice the next morning.

It was a fascinating case. I've read and heard about Munchausen but never really grasped it until now. I was just blown away that someone could lie like that--especially given the fact that he signed the paper giving me permission to get his records from the other hospital! Either he thought I was really stupid, or he's not the brightest faker ever to waste the hospital's and taxpayers' resources. And I'm flabbergasted--what would make someone want to be in the hospital and have unnecessary, risky testing done (he also had a history of wanting surgery he didn't need)? Does he just crave attention? Is he just drug seeking? I don't think he is a hypochondriac (hypochondriacs really believe they're sick, Munchausens don't).

On the same day, we had an interesting ethical situation. We had a patient who was brain dead, in other words, her heart was still beating since we had her on a ventilator and were pumping her full of drugs, but she had absolutely no neural function. For all intents and purposes this meant she was dead--not in a vegetative state--for her to wake up would be just as miraculous as a skeleton regrowing flesh. She had a very large extended family visiting. The resident was planning to meet with them and tell them that the patient was dead and they should say their goodbyes before she was taken off the vent. However, the attending who was covering for the week walked in, smiled, and told them that her heart and lungs were doing great and that the neurologists would do a test of her brain. The family in the room sighed with relief and thanked God, thinking that there was now a chance of the patient's recovery. The residents' jaws dropped open in shock.

Immediately after in the residents' room, behind a safely closed door, the attending and residents argued for about 20 minutes about the proper way to handle the situation. The attending was adamant that he had just provided the family with hope, and that they should slowly, over the next day or two, break it to them that that patient would not recover. The residents (and I, silently) were strongly of the opinion that they needed to be honest. The attending didn't give in, and left. The residents then spoke to the neurology consult attending, who was understandably furious. He called our attending to yell at him, then met with the whole family and told them she was dead. They took it well, and said their goodbyes before her heart stopped the next morning.

This episode has been the subject of much discussion over the last few days. I think it demonstrates a great difference in the way that different cultures and generations think about death and the role of the physician. Our attending was an elderly Asian man, and came from an era and a culture in which physicians took a paternalistic approach and gave patients hope even when there was none. An era in which they could start chemotherapy without ever informing the patient that he or she had cancer. We, and virtually all doctors in America today are products of informed consent, in which there can be no greater travesty than to be anything other than brutally honest with a patient, even when it hurts. Maybe we're wrong, or at least not totally right. But it's how I would want to be treated.

The Match

2008-03-21T07:52:00.001-07:00

Good news and bad news: the good news is that I have a job next year! The bad news is that it's only guaranteed for one year. Last Monday I had the unpleasant experience of opening my email and finding that I had not matched into a surgery program--it came as a rather nasty and completely unanticipated shock. Tuesday I went to my school for the scramble--in a way I am glad that I experienced it, but I still would not wish it on my worst enemy! I and my ten fellow unmatched students, most who were handling it well, but some who had obviously been crying all night, met in a conference room and got a pep talk from our deans. They then set each of us up in a private office and provided each of us with a personal assistant to take calls and send faxes. The list of open programs (there were only two categorical surgery spots) was then released across the country at 11:30 EST, and at 12:00 we all started madly making calls and re-applying on ERAS. My advisor was there as well calling all the program directors she knew. Blessedly, this quickly ended for me when the program director of my school's program called and offered me a prelim spot, which was what I had been hoping for. I snatched it up, and now have a job, and at the program I had been hoping to get into from the start. Unfortunately this means that the next year is going to be somewhat stressful as not only will I have the responsibilities of a new physician, but I will have to try to find a place to go for the next four years (this is just one other example of the benefits of being a Calvinist--I know God's in control:). It should be interesting! Thankfully the match went well for my friends, though there were still some tears (more from weeks of pent-up emotion than actual disappointment. One bit of advice to students applying next year: do NOT believe anything programs say regarding how they plan to rank you. They are lying). Most of them ended up staying here--in fact, of the 11 students and students' spouses in my Bible study, nine will remain here.

Some of the things I am most excited about for the next year are kind of silly--I am really looking forward to shedding my short white coat. I remember at the beginning of third year how pretentious I felt wearing it, now it's just humiliating. I'm looking forward to being able to be able to sign my own orders (scared too though!). I'm looking forward to being able to tell patients I'm a doctor (I have to decide how I'm going to introduce myself--it will either be "Dr. Emlyn" or "Chris Emlyn, one of the residents". I'm just not a "Dr. Chris" kind of guy). I'm looking forward to parking in the structure and not in the lot two blocks away (5-10 more minutes to sleep each morning!). I'm looking forward to having medical students, though I kind of wish I wouldn't have them until a month or two into internship. I'm really looking forward to having a salary, though I plan to remain in my cheap apartment for a while at least.

Cardiology

2008-03-08T13:50:00.000-08:00

I'm back. On my arrival I found that my car had a 5" thick slab of ice underneath and surrounding it, preventing me from getting it out of the driveway. I had to walk to the hospital Sunday, then take a hammer to the ice that afternoon to get just enough asphalt clear so that the car's wheels had enough traction to back out.

I flew back Saturday and started inpatient cardiology Sunday morning. This apparently is going to be a rough month--I only get three days off not counting the day of my flight. There are two senior residents, four interns, and two senior students on the team. One plus is that students don't take overnight call. However, since the on-call, pre-call, and post-call interns don't take admissions during the day, this leaves me, the other student, and one intern to admit all new patients. As the interns have clinic sporadically throughout the week, this means that the other student and I can get stuck with more than our fair share of work. Like yesterday, when I left the hospital at 9:00pm. Not fun. I got today off but have to go in tomorrow. I paged the resident at noon to find out what time I needed to come in--they were still rounding...at noon...this does not bode well for tomorrow, especially as three of my patients are completely new to me, and I'll have to see several patients I don't know at all who belong to the other student and interns. At least I'm learning a lot.

There is a light at the end of the tunnel. This month is my last month as a student of clinical work. In April I'll be on radiology, during which time I'll get weekends off and plan to leave the hospital early in the afternoon on the weekdays. Then two weeks of "preparing for internship", and graduation! In less than two weeks now, I'll find out where I'll be spending the next five years.

Surgery

2008-02-17T17:06:00.000-08:00

I have not been able to post updates as my temporary apartment does not have an internet connection. For the last two weeks I have been back in California at what I believe is one of the most beautiful locations in the US if not the world. The hospital is nestled in the green hills, minutes away from the beach, and it's been in the 60s to 70s. I am not looking forward to the end of this month.

I love the surgery program as well--everyone is really nice, and I feel like I'm home again in a way I haven't felt out of state. It's small, but I'm starting to think that's more of a strength than a weakness. Unfortunately, I did not get an interview here, so unless I figure out a way to get the program director to rank me, I won't be coming back next year. Which would be fine as God has clearly already ordained the best place for me to match into, but I wouldn't complain if it was here (not that I would if it's not).

I read a book last week called "God's Harvard", a book written about Patrick Henry College (a university founded by Michael Harris several years ago that is attended primarily by former homeschoolers) by a liberal journalist from NY. She spent a year and a half interviewing students and faculty, attending classes, and shadowing the students. The book is very biased, but I was actually surprised that it wasn't as biased as I would have expected. She definitely focuses heavily, and I'm sure disproportionately on internal strife, but it's clear throughout the book that she's not sure what to make of the students.

She details the principles of the school (that focus on serving God) fairly accurately, but never really overcomes her surprise that the teenagers who attend the school actually want to dress modestly, court rather than date, put families before careers, etc. Throughout the book she searches for chinks in the students' armor, and does her best to convince herself that they are brainwashed by their parents or just stupid. She is unable to convince herself however, as most of the students are academically successful, many came in with perfect SAT scores, and they are stunningly good at getting jobs and internships in Washington. She'd like to mock them but can't as they are too smart and would like to hate them but can't as they are too kind. She's left with a strange mix of grudging admiration and fear.

Even after finishing, I'm not totally sure what her purpose was in writing the book, and I'm sure it wasn't much of a seller (I accidentally found it on the bargain table at B&N), but it was a fascinating read.

Vacation

2008-01-25T14:43:00.000-08:00

My two month vacation is rapidly coming to an end. After a beautiful month in the balmy climes of that sunny and joy-filled land (California), I have just returned to the ice-pit in which I go to school. Fortunately, I'm going back to California for an away rotation very soon. Hopefully it will provide me with something worth posting. Unfortunately the price of something worth posting will be my having to get out of bed between four and five AM every day (after two months of sleeping 9-10 hours every night--why surgery, again?)

I constantly go back and forth in my opinion of where I am currently living. While I'm inside my car or apartment, I find the snow to be very beautiful, and somewhat exotic (having only seen snow a handful of times before moving here). When I go outside my car or apartment my optimism rapidly plummets and I can't help pondering the striking similarities between this city and the ninth circle of hell.

Today I dropped by school and found that it was an interview day for pre-meds. I realized with a jolt that by the time they get to their third year of medical school I'll be their senior resident. By the time they're interns, I'll be their chief, about to graduate and get my first attending job. Crazy. Time has gone by so fast. And I'm starting to feel very old (no comments from those who know my age please:).

The Way I See It part II

2008-01-08T15:12:00.000-08:00

The Way I See It #232
You simply can’t make someone love you if they don’t. You must choose someone who already loves you. If you choose someone who does not love you, this is the sort of love you must want.
-- Israel HorovitzPlaywright/screenwriter, from his new play, The Secret of Mme. Bonnard's Bath.
But if someone already loves you then that person is loving someone (you) who doesn't love him or her. So if you choose him or her then essentially that person is making someone love him or her who doesn't. So really this means either that this statement is completely false or no one can love anyone.

The Way I See It #235
In three decades of polling, I’ve found that while individuals make mistakes in judgment, America as a whole rarely does. A collective wisdom emerges from a poll or vote that is far greater than the sum of its parts.
-- John ZogbyPollster, president and CEO of Zogby International.
snerk

The Way I See It #236
Scientists tell us we only use 5% of our brains. But if they only used 5% of their brains to reach that conclusion, then why should we believe them?
-- Joseph PalmStarbucks customer from Oshkosh, Wisconsin.
Actually if you've ever talked to a scientist you would know this 5% thing is hogwash. But even if true it would beg the question if Joseph Palm is only using 5% of his brain then why should we listen to what he says?

The Way I See It #242
Children are born with such a sense of fairness that they will accept no less than equal treatment for all. I know – I have three. I hope that as they grow, they keep that sense of justice and learn to challenge the old adage that life’s not fair. It should be, in so far as we have control of it.
-- Beth Vanden HoekStarbucks assistant manager in St. Louis, Missouri.
I think she's mistaking selfishness ("his cookie's bigger than mine"--"is not"--"is too!") for desiring fairness. If that's how she defines a "sense of justice" I don't think she needs to worry about her children losing it as they age.

The Way I See It #247
Why in moments of crisis do we ask God for strength and help? As cognitive beings, why would we ask something that may well be a figment of our imaginations for guidance? Why not search inside ourselves for the power to overcome? After all, we are strong enough to cause most of the catastrophes we need to endure.
-- Bill ScheelStarbucks customer from London, Ontario. He describes himself as a "modern day nobody."
You're a figment of my imagination.

The Way I See It #250
In reality hell is not such an intention of God as it is an invention of man. God is love and people are precious. Authentic truth is not so much taught or learned as it is remembered. Somewhere in your pre-incarnate consciousness you were loved absolutely because you were. Loved absolutely, and in reality, you still are! Remember who you are!
-- Bishop Carlton PearsonAuthor, speaker, spiritual leader and recording artist.
I'm remembering my preincarnate consciousness-- I thought you were irritating then too.

The Way I See It #276
Anger is contagious.
-- Sandra CisnerosAward-winning author of Caramelo, The House on Mango Street and Loose Woman.
And can also be induced along with sheer disgust by reading her works--such as Woman Hollering Creek--in a location--such as an ethnic American literature class one must take in order to graduate...yeah...still a bitter taste in my mouth over that.

The Way I See It #230
Heaven is totally overrated. It seems boring. Clouds, listening to people play the harp. It should be somewhere you can’t wait to go, like a luxury hotel. Maybe blue skies and soft music were enough to keep people in line in the 17th century, but Heaven has to step it up a bit. They’re basically getting by because they only have to be better than Hell.
-- Joel SteinColumnist for the Los Angeles Times.
Is it humanly possible to miss the point more than this?

The Way I See It

2008-01-07T11:33:00.000-08:00

Question of the day: Where does Starbucks find all the imbecilic quotes they put on their coffee cups? Here for your viewing pleasure is the quote I had on my cup the other day:

The Way I See It #279

Beware of turning into the enemy you most fear. All it takes is to lash out violently at someone who has done you some grievous harm, proclaiming that only your pain matters in this world. More than against that person’s body, you will then, at that moment, be committing a crime against your own imagination.
-- Ariel DorfmanNovelist, playwright and essayist.

Perhaps later I'll post more and proceed to mock them with my customary scintillating wit.

Journals

2008-01-02T22:17:00.000-08:00

I have not done anything terribly exciting--as I currently am on a month off I have pretty much been relaxing continuously. I have been trying to read from Sabiston or from surgery journals a couple times a week to keep from completely vegging out. I found one very interesting article looking at the attrition rate in surgical residencies two years before and two years after the installation of the 80 hour work week (before a few years ago there were no work restrictions for residents so it was commonplace for surgery residents to work 100-120 hours every week, and be on call every other day--now residents cannot work more than 80 hours/week or their program can be put on probation [interestingly I just read that residents will be limited to 48 hrs/wk in the UK starting in 2009--I find that kind of scary]). Surgery residencies have traditionally had a pretty high voluntary drop-out rate of about 20%--residents tend to leave for more lifestyle-friendly residencies such as anesthesiology, emergency medicine, or family medicine. One would thus think that the attrition rate would decrease now that work hours are restricted. Surprisingly the rate has actually increased--the study I read showed the the typical surgery program lost 0.6 residents per year before the 80 hour work week, but now the typical program loses 0.8 residents per year. Granted this study only looked at a period of four years, and most likely the programs were not as compliant with the 80 hour work week two years after its installation as they are now, but I thought it intriguing nonetheless. The authors' hypothesis was that people who previously would not have applied to surgery due to its lifestyle thought that with the 80 hour work week residency would be more manageable--only to find out once they started that even with only 80 hours/week it was still quite rigorous.

Interview Trail

2007-12-14T19:06:00.000-08:00

I just got back from a 1.5 week long road trip containing five interviews. These interviews all pretty much follow the same format. Dinner with residents the night before, then an introduction by the program director and/or chair in the morning followed by 3-4 interviews with the program director and several faculty. Usually there is a lunch at the end, and residents pop in and out throughout the morning. Virtually all the interviewers ask the same questions, and I am now at the point of reciting the same answers over and over. One of the nice things about interviewing for residency is that the programs want the applicants to have a favorable impression of the program. One of the ways they attempt to give this is by providing housing and meals for the interviewees. While one or two programs just sent me a list of suggested hotels, about half provide hotels at 1/3 normal price, and about half actually pay for the hotel altogether--usually very nice hotels. For instance, I have now become accustomed to having a king-sized bed and a room that is magically cleaned every time I leave it. I have had several new experiences in the last two weeks. I have visited two new states, tried raw fish for the first time, had thai food for the first time, slept in a king-sized bed for the first time, and had a jacuzzi in my bedroom for the first time.

Also novel to my experience is going to a restaurant and having the entire menu as fair game. Usually when I eat out I limit myself to a cheaper entree and don't even get a soft drink. There is something incredibly liberating about going to a nice restaurant and having no boundaries--at most of the pre-interview dinners we ordered several very good appetizers (which included my first sushi experience), got entrees without regard for cost, then followed it up with dessert. The best evening of all was last night--I walked into my hotel room, threw down my bags, then looked up to realize that there was a two-person jacuzzi five feet from my king-sized sleep-number bed. I was a little shocked. I actually still am. I didn't have a chance to try it out right away as I had to get to the dinner. We went to a restaurant attached to the local Hilton and proceeded to have quite possibly the best dinner of my life. We started out with several fantastic appetizers. Then I got my beef tenderloin garnished with crab and smothered with some delicious sauce. Words cannot describe how good it was. It alone made the whole trip worth it. Stuffed, I followed it up with blackberry cabernet sorbet. When I got back to the hotel, I filled my jacuzzi with steaming hot water and lounged with the air jets massaging my tired body. I then dried off, climbed into my sleep number bed, adjusted the settings to the perfect firmness, and drifted off to sleep. Unfortunately I then had to wake up at 5 am to get ready for the interview. I was very tempted to skip the interview and stay in my room until check-out time.

I still have a couple more interviews. I have no idea how I am going to rank the programs. I've liked all of the programs I've interviewed at, and I think all of them turn out well-trained surgeons. There are a couple I know I'm going to rank low, but because of location rather than any deficiency in the program. One of the biggest decisions I have to make is whether I'm going to try to stay where I am or not. My problem is that whenever I'm interviewing, I'm attracted to the program I'm interviewing at. I think I am going to have to wait a week or so before starting to seriously evaluate the programs.

Interviews

2007-11-27T09:02:00.000-08:00

My ER month is almost over. I had my last shift last weekend, and went on an ambulance ride-along yesterday. This has been the best schedule during all my time in medical school. I even managed to go home for a couple days for Thanksgiving! I do unfortunately have to take an exam for the first time in fourth year on Thursday which I am wildly unprepared for.

Interview season has begun in earnest. I had my first a couple weeks ago--I liked the program and the people, the location however left something to be desired. The next three weeks will entail a lot of travelling, going to a lot of awkward night-before dinners, being asked the same questions (why surgery? why this program? what are your strengths/weaknesses?) dozens of times by dozens of people, having to ask the same questions (what are the best points of this program?) dozens of times, and driving a lot.

The question I hate with a passion, is of course, the strengths/weaknesses question. The strengths question kind of makes sense, but I don't understand the weaknesses question. Clearly if the interviewee has weaknesses that should be a concern, s/he is not going to admit them to the interviewer. Which leaves the old strategy of taking something that's actually a strength and pretending it's a weakness (I care too much. I work too hard. I have to get things just right. Patients say that I'm so great that something must be going wrong because no one can be that perfect. Etc.) which naturally everyone sees right through. Being asked these questions so many times, I am constantly tempted to deliver a flippant answer with a totally straight face. Here are some examples:

Strengths:

I've found that my telekinetic abilities are a stunning asset in virtually every situation.

In addition to my commitment to surgery, I have many interests outside of medicine. For instance; last summer I learned to translate hieroglyphics, wrote a best-selling novel, and just for fun discovered how to divide by zero.

Weaknesses:

Patients say I don't empathize well.

Sometimes I think I like cutting people too much.

I faint at the sight of blood.

Technically, I'm not supposed to be within 500 ft of several people in this town.

My therapist tells me I have some issues I need to deal with before being around patients. But it's all right, the voices in the ceiling say I'm good to go.

I don't deal with correction well.

In stressful situations I tend to break down.

ER

2007-11-11T11:26:00.000-08:00

My peds sub-i ended uneventfully. Last week I started in the emergency department--my duties consist of being present for 11 eight hour shifts!!! It's been beautiful. I feel like I've gotten more sleep in the last week than I had in the previous months. I don't have to think about patients when I come home, because they'll all be new when I go back. I don't have to round. There's a ton of variety. And I have more days off than on.

There have been several interesting patients. A pleasantly psychotic elderly man who came by ambulance because his leg was bleeding (the mysterious "they" had pricked him with something--the bleeding was long stopped by the time he got to the ER). A psych patient tachycardic for no apparent reason. Multiple people with obscure abdominal pain. A lady who wanted ativan because her grandfather had just been admitted to the ICU and was dying (which brought up an interesting debate of the appropriateness of using drugs in a natural grieving process--the senior resident wasn't going to give any, the attending wasn't at first but decided to after talking to her). Multiple traumas, mostly blunt.

It's been good. If I didn't like surgery so much, I think I would be very tempted to pursue ER.

Goal Met

2007-10-27T07:58:00.000-07:00

Today is my third day off of the month, and I have tomorrow off too. It's an amazing feeling. I really have no plans aside from errands (and Reformation Day Party at church tomorrow evening). I was going to do a lot of non-medical reading and possibly Stargate Atlantis watching, but I have been somewhat thwarted--my netflix account has sent me the third disc but not the second, so I am faced with the dilemma of either watching episodes out of sequence which is a pet peeve of mine, or waiting until next week to watch them at all. Similarly, I requested from the county library system the first three books of a series I am about to start, and I got an email yesterday informing me that they are holding the second and third books, but don't have the first yet. Annoying.

My call night on Thursday was the best call night of any rotation I have been on. Our only admit (who could totally have gone to a regular floor) was a bronchiolitis kid with no significant medical history and on no medications. I staffed him by 10:00, then went to my call room. I had to watch for some labs which were back by 11:20, then I went to bed. And didn't get another page until 3:45! I was able to take care of it with a phone call, went back to bed, and got up at 6:00. I saw the senior resident a little later, and he told me that nights like that never happen. Of course, the night wasn't as restful as it sounds as evidenced by the fact that I still came home and slept six hours straight before going to bed for the night. Call night sleep is very superficial and interrupted--one is constantly waking up, checking the pager to make sure one hasn't been paged and slept through it, checking the computer to make sure there aren't any crazy lab values that no one has told you about, waking up to FYI pages from the nurses, as well as going over patients constantly in one's head to mentally check and re-check that one hasn't missed anything. But I'll still take a night like that over a night like my first and second call nights any day (or night, as it were).

Yesterday I finally achieved my highest goal for the month--I discharged the last of my original patients.

6 down, 2 to go

2007-10-23T14:27:00.001-07:00

This rotation is winding to a close--technically, I have a week with two call nights left, but since I get the weekend off (!!!) it seems like less. As I have said, this has been a very valuable rotation for my over all development as a physician, but it is somewhat exhausting.

We've had some very sad cases recently. One is a 3 month old boy who underwent horrible parental abuse that left him severely brain-damaged. My last two call nights I've been called to see him several times for trouble breathing/low oxygenation. Sunday night was particularly bad, and after several hours during which time we had to call the critical care fellows and attending in to see him, he was finally transferred to the PICU. Unfortunately, he will likely continue to worsen--what makes it particularly sad is that his mother (father is in jail) refuses to look at the situation realistically and thinks that the infant will heal completely. Underlying this denial is the fact that if the infant dies, her boyfriend will be tried for murder instead of child abuse. His grandmother is very on top of things and is in the room constantly--she is trying to reason with his mother.

The saddest case so far is an 11 month old I admitted last week. She had a heart defect which had been stable for the last couple months. She developed mild shortness of breath a couple days before her admission. Her parents had decided to transfer her care a month ago, so rather than go to the hospital at which she was established, they came here. She was very stable, and didn't seem to be very bad off. The cardiologist decided to do an echo in a couple days. I left Friday night, everyone thinking she was fine. When I came back Sunday morning, I found out that out of the blue she had suddenly worsened Saturday evening, was transferred to the PICU, and then died early Sunday morning. I can't imagine how devastated the parents must feel.

On a happier note, the little girl who has been here for months is going to get a new heart tonight.

On a different note, for some weird reason I just cannot stop eating on this rotation. Usually my diet is pretty healthy, but these last few weeks I have found myself with an insatiable craving for greasy food. It's worst on call nights, which I think is reasonable as my body is unusually stressed and fat has the most calories per gram. However, today for instance, I had lunch, then went to the resident lounge to get coffee and a danish. After the danish, I ate a donut. Then I came home and ate a chocolate bar. I'm really going to have to watch myself in residency.

To sleep or not to sleep

2007-10-15T15:48:00.000-07:00

This was my black weekend (on call Saturday therefore no days off). It really wasn't too bad, we had an unprecedented one admission which came early in the night. At nine, I realized I had nothing to do, so guiltily went to my call room and laid down, pagers by my head, hoping that no admissions would come in--and none did! I still did not get to sleep, as I was paged continuously about issues. Most I had to go see the patient for, thankfully most of those ended up being nothing I couldn't quickly handle. A couple of the pages I could handle over the phone without even getting out of bed. So I spent much of the night in a half-awake/half-dazed state, getting up about every 30-60 minutes. Even without sleep though it was much superior to admitting people non-stop. There was one patient that was a problem throughout the night--he was persistently bleeding from his mouth and nose--most likely from a high flow nasal cannula. It looked a lot worse than what it was, and the nurses were getting a little tense, particularly after his O2 saturation dropped into the 20s. This however, is not uncommon for him, and he came right back into the 90s by the time I got to his room.

When I left the hospital, I thought that I would likely not need to sleep as much in the afternoon since I had had a peaceful night. Ha. I started dozing after I had lunch and went to bed a little before 2pm. I woke up and looked at the clock--it was 3:30am. I slept more until 5am when I got up--that's the first time that has happened to me, usually I get up for a couple hours in the evening. So my n=1 study seems to indicate that constantly interrupted half sleep is not as restful as no sleep at all.

My patient with heart failure, now improved, failed her swallow study. Was scheduled to get PEG tube (tube that goes into the stomach for feeding) last (I think) Wednesday, consents were signed. The anesthesiologist however, wasn't comfortable putting her under anesthesia without talking to the mother. Problem is that mom's a flake and it's impossible to get a hold of her. So the procedure was postponed until tomorrow. This morning she spiked a fever. She's fine, but anesthesia may not want to put her under. The biggest issue is that the only reason she's still in the hospital is that she is waiting for a PEG tube. Frustrating.

The saga continues

2007-10-12T14:49:00.001-07:00

I'm pretty tired. My last call night was just non-stop, I admitted four patients, all of whom required about two hours each just to read through their charts. One was a four year old boy who had just gotten a heart transplant, and was transferring out of the PICU (where he had been for three months previously). One was a girl with a super-rare genetic disorder who was admitted to the PICU in heart failure, and transferred to us when she was stabilized. Four of the six patients I talked about in my last post are still here.

I have mixed feelings about this rotation. In general, I do not like it, but I can't put my finger on why. I'm not a big fan of being awake for 30 hours straight, but have been on other rotations without too much trouble. I think the biggest thing is that these patients have very complicated, chronic conditions that are generally beyond my level of understanding. Rounds in the morning are also painful, being hours long, but I have to pay close attention because one out of four nights I'll be watching over all the patients, and on the weekends I'll be rounding on some of the other interns' patients. That all being said, I have to admit that in the long run I think this rotation is going to be very good for me in many ways. First, patients with issues like heart transplants are very intimidating to me, and this rotation has been helpful to make me realize that the basics of medicine still apply to them. Second, I am forced to follow more patients than I ever have before more closely than I ever have before, and I have to keep a lot of information in my head about each one. Third, it makes me have to put into practice all the things I know in theory--like what to do if someone spikes a fever, or has decreased urine output. At this point I put things into practice very badly, so it is a good thing that I have a senior resident take call with me to sign all my orders and step in when I am clueless. Also, I never fully realized how many stupid little details have to be managed and ordered.

I'm starting to feel like I have a better grasp on things, particularly since I am now only following five patients instead of nine. I felt better after I asked the interns what they thought of this rotation compared to others, and they told me that they had similar frustrations to mine.

I'll be on call tomorrow--then I'll be halfway through my calls! And once this rotation is over, I'll have ER for a month (shift work!) then two months totally off (except for interviewing)!

IICU

2007-10-07T11:03:00.000-07:00

I started my sub-internship in the intermediate intensive care unit at our children's hospital on Monday. It's been...intense. Today is my only day off for the first three weeks of October. I take call every fourth day. Monday I admitted three patients overnight, and rounded on them in the morning. At noon Tuesday I found out that I would have to round on four new patients Wednesday in addition to my patients. Essentially, it meant that Wednesday morning I had to round on six patients, all very complicated, four of whom I knew nothing about. My presentations were shaky at best. I stayed two hours late that day to go over their charts (some had been in the hospital for several months) which aided considerably in rounds the next morning. Friday I took call again--I admitted 5 new patients overnight, giving me nine patients total. As these patients are all far more complicated than any patients I've taken care of before as a third year medical student (virtually no real responsibility) it's been challenging. I've been told that I'm doing well fortunately, and I think the fact that I'm working hard even though I'm not going into peds helps my reputation as a sub-i a lot.

Some of my patients over the last week:

1) Ten year old boy w/new onset diabetes presenting in diabetic ketoacidosis. Gave him a lot of IV fluids and IV insulin, sent him home two days later.

2) 18 yo girl with Charcot-Marie-Tooth disease (neurological disorder). She's ventilator dependent, but very stable. We have her because there was a question of negligence on her parents' part--they are fighting to keep her. Lot of messy social stuff, but my gut feeling and the feeling of the attendings is that her parents are being unfairly judged, and she will most likely go back to them, hopefully this week.

3) 3 yo girl with history of congenital heart disease, underwent repair several years ago, here with heart failure. Worsened after tonsillectomy. Slowly improving, though has a lot of stuff going on and will need to be very closely followed when she leaves.

4) 3 yo girl with congenital heart defects, needs a new heart. She's been here for months just waiting. A few nights ago I started praying that she would get a new heart, but then suddenly realized that for that to happen, a healthy child somewhere is going to have to die. Very sad situation.

5) 10 yo girl with extensive medical history, had a bilateral lung transplant several months ago. A couple of her labs from home were a little off, so she was admitted with the concern of a line infection. She's completely asymptomatic, but as she is immunosuppressed there is still a concern. Hopefully the concern is baseless and she'll go home soon. Interestingly, she has an incredibly bizarre diet in which she eats horrendous amounts of food, but remains a normal-sized ten year old. Apparently, she eats every couple hours, and will sit down and eat five hamburgers at a time, or will order 75 pieces of salami and eat them in one sitting, dipping each piece in salt, etc. There's a suspicion that she may have a biotinidase deficiency.

6) 4 yo girl with neurologic devastation after complete cardiopulmonary arrest a year ago (she was totally normal before), believed to be secondary to parental abuse (also has history of a couple broken limbs which is a serious red flag). She is trach and g-tube dependent, has spastic limbs, cannot communicate, and has a seizure disorder. She's in foster care now--her parents legally have custody, but are not allowed to be alone with her. She had an episode the morning of her admission in which she stopped breathing, was bagged for five minutes, then revived and has been fine since. We think that her trach was momentarily clogged with a mucus plug. Her mother came to spend the night in the hospital with her, and acted like a concerned parent--her foster mom told me that despite the fact that her parents have full visitation rights, this was the first time she had met the biological mother. I didn't have a lot of sympathy for the biological parents, and had to bite my tongue when I heard the biological mother complain on the phone about the court system.

And I have several more. The vast majority are far more complicated than I am comfortable with, and honestly I have a very limited understanding of what the full scope of their disorders are. This is a pretty intimidating rotation, and even though I know I'll learn a ton, and I'm grateful for the fact that it really pushes me to be far more efficient than I've ever been before, and to know my patients well, I can't help wishing every once in a while (usually at 2:00am when I've done 3 admissions and have two more coming) that I did the family practice sub-i instead, which caps at two admissions a night and has patients with simple problems:). I have learned that I really prefer to deal with patients with one acute problem, with maybe the occasional well-controlled chronic problem as opposed to here where patients have 5 medical problems and take 30 medications every day. Maybe that will change over the years as my knowledge increases and my general competency improves. One really weird thing about this rotation is for the first time I am the first point of contact for my patients for the nurses--they ask me questions about what they should do, and expect me to have an answer. This is particularly difficult at night when I am covering almost 30 patients, and don't know most of them. Thankfully, there is a senior resident available who has to sign all my orders, and is available if I need help with something.

Done with neph

2007-09-28T15:04:00.000-07:00

Today was my last day of nephrology. It was a quiet week--I don't think I did any consults. The last three days we have finished rounds before noon and I have spent the afternoons wandering aimlessly through the hospital and drinking a lot of coffee (I drink way more coffee on light rotations than on busy). Yesterday I studied a lot, today I played games on my PDA. I think this month has gone by faster than any other rotation I've been on.

Monday I'll start my pediatric sub-i in the intermediate ICU of our children's hospital. I'll share call with three interns--naturally, I'll be up Monday.

I still only have one interview invitation--fortunately most of the other students I know who are applying to surgery also only have one or two, I think a lot of programs haven't even started reviewing applications yet. My friend who is applying to family medicine, on the other hand, has 16 interview invitations a week after turning his application in.

Busy

2007-09-21T10:16:00.000-07:00

Things have picked up this week. Instead of leaving sometime between 1 and 4 it's been around 6 or 7. Today though, we finished rounding early and have not gotten any consults. Which is why I'm typing this now.

One of the consults I saw on Monday was a woman in her early 30s who came in with a blood pressure of 220/100, elevated troponin (measure for heart attack), and chest pain (we saw her because she's had renal failure for the last few months). The EKG showed some s-t depressions but no elevations. The cardiologists weren't sure if she had had an MI or just a bad hypertensive episode. What was particularly interesting was that her brother had been admitted the day before for a heart attack. Yesterday she was transferred from the ICU to the floor in the room across from her brother. When I went to see her, she and her brother were both playing cards in her room in their hospital gowns. It was kind of funny in a not-funny sort of way.

We've had a lot of really sick people who have very poor prognoses. For most of them their kidney disease is just the tip of the iceberg.

I got my first interview invitation a couple days ago--as I had gotten two rejections the week before I was (am) very excited--I might actually be a surgeon someday.

Sitting around

2007-09-13T11:44:00.001-07:00

We rounded this morning--we finished around 1:00 and there were no consults so I went home and asked the NP to page me if anything comes up. While I'm definitely not complaining about the free time, and there is something kind of fun about being able to leave a note in the chart and have someone else actually do all the work of caring for the patient, I find that I'm looking forward to my pediatric sub-I next month. Hopefully in 4 weeks I won't re-read this post and think what an idiot I was for wanting more to do.

Conference

2007-09-11T18:12:00.000-07:00

It's been slow. I go in on the morning and write a note on 2-4 patients. We round for a couple hours. In the afternoon I read or occasionally see a consult. I go home at 4-5. Tuesdays we have case conference from 3-4. Last week I left at four with all the other students and residents because the PAs told me I didn't need to stay for the 4-5 conference. Naturally, the next day my attending asked why I hadn't been there (the PA told her she told me to go home). So, today I stayed for the 4-5 conference--all the students and residents left, leaving me in a room full of many attendings and 3 fellows. I asked my attending if I should stay and she gave me an non-commital answer which meant that I should. So I stayed--the speaker came fifteen minutes late. He then tried to get his power point presentation up--he was gradually joined by three other doctors who tried to help him. I looked around and realized that my attending had left. At 4:30 the chief announced the talk would be postponed until next week. This whole situation struck me as incredibly amusing--all these doctors completely thwarted by a stupid computer. It also showed how dependent we are on power point these days--public speaking has become a lost art.

Gulliver's Travels

2007-09-07T14:35:00.000-07:00

I've been debating whether or not I should post this, and have decided that I will. Let me preface it by saying that there are many, many really great lawyers, I have known several great God-fearing lawyers, and I am of the strong opinion that we need many more Christian lawyers and would in fact encourage Christians to go into law. That being said, here is a passage from Gulliver's Travels (published in 1726), that, if nothing else, I think hits home the fact that there is nothing new under the sun. Gulliver is talking to his houyhnhnm master about law in Britain:

I assured his honour, that law was a science wherein I had not much conversed, further than by employing advocates, in vain, upon some injustices that had been done me. However, I would give him all the satisfaction I was able.

I said there was a society of men among us, bred up from their youth in the art of proving by words multiplied for the purpose, that white is black, and black is white, according as they are paid. To this society all the rest of the people are slaves.

For example, if my neighbour hath a mind to my cow, he hireth a lawyer to prove that he ought to have my cow from me. I must then hire another to defend my right; it being against all rules of law that any man should be allowed to speak for himself. Now in this case, I who am the true owner, lie under two great disadvantages. First, my lawyer being practised almost from his cradle in defending falshood; is quite out of his element when he would be an advocate for justice, which as an office unnatural, he always attempts with great aukwardness, if not with ill-will. The second disadvantage is, that my lawyer must proceed with great caution: or else, he will be reprimanded by the judges, and abhorred by his brethren, as one who would lessen the practice of the law. And therefore, I have but two methods to preserve my cow. The first is, to gain over my adversary's lawyer with a double fee; who will then betray his client, by insinuating that he hath justice on his side. The second way is, for my lawyer to make my cause appear as unjust as he can; by allowing the cow to belong to my adversary; and this, if it be skilfully done, will certainly bespeak the favour of the bench.

Now, your honour is to know, that these judges are persons appointed to decide all controversies of property, as well as for the tryal of criminals; and picked out from the most dextrous lawyers, who are grown old or lazy: and having been byassed all their lives against truth and equity, lie under such a fatal necessity of favouring fraud, perjury and oppression; that I have known some of them to have refused a large bribe from the side where justice lay, rather than injure the faculty, by doing any thing unbecoming their nature or their office.

It is a maxim among these lawyers, that whatever hath been done before, may legally be done again: and therefore they take special care to record all the decisions formerly made against common justice, and the general reason of mankind. These, under the name of precedents, they produce as authorities to justify the most iniquitous opinions; and the judges never fail of directing accordingly.

In pleading, they studiously avoid entering into the merits of the cause; but are loud, violent and tedious in dwelling upon all circumstances which are not to the purpose. For instance, in the case already mentioned: they never desire to know what claim or title my adversary hath to my cow; but whether the said cow were red or black; her horns long or short; whether she were milked at home or abroad; what diseases she is subject to, and the like. After which, they consult precedents, adjourn the cause, from time to time, and in ten, twenty, or thirty years come to an issue.

It is likewise to be observed, that this society hath a peculiar cant and jargon of their own, that no other mortal can understand, and wherein all their laws are written, which they take special care to multiply; whereby they have wholly confounded the very essence of truth and falshood, of right and wrong; so that it will take thirty years to decide whether the field, left me by my ancestors for six generations, belong to me, or to a stranger three hundred miles off.

In the tryal of persons accused for crimes against the State, the method is much more short and commendable: the judge first sends to sound the disposition of those in power; after which he can easily hang or save the criminal, strictly preserving all the forms of law.

Here my master interposing, said it was a pity, that creatures endowed with such prodigious abilities of mind as these lawyers, by the description I gave of them must certainly be, were not rather encouraged to be instructors of others in wisdom and knowledge. In answer to which, I assured his honour, that in all points out of their own trade, they were usually the most ignorant and stupid generation among us, the most despicable in common conversation, avowed enemies to all knowledge and learning; and equally disposed to pervert the general reason of mankind, in every other subject of discourse, as in that of their own profession.

Wasting time

2007-09-07T14:15:00.000-07:00

This is a very light service--we have an attending, a medicine resident, and 2-3 PAs/NPs depending on the day to monitor about 12 patients. My duties consist of visiting my two very straightforward patients in the morning and writing a note. So far I have also done one H&P on a new patient. The rest of the day we round, then I go home (5:30 yesterday, 1:00 today:). The attending is constantly teaching me and the resident though, which is a rather unique experience for me--since the teaching occurs in between patients on rounds, the PAs find it a little frustrating though. Since this is an elective, I also get weekends off.

Yesterday I went to a medicine M&M for the first time (when I was on medicine last year, M&M and grand rounds were cancelled for the summer)--it was the total opposite of surgical M&M which consists of residents' presenting their patients who either died or had something bad happen to them, followed by the residents' being grilled and yelled at by the attendings (despite the fact that the attending is the one who actually made the poor decision). The medicine M&M however did not pick on the residents at all--one of the chief residents presented a patient and the chairman called on attendings to ask what their thought processes were. I tend to favor the medicine method, though I have to admit I don't think they needed to spend an hour on the one patient (surgical M&M goes over at least 5 patients in an hour). I went to medicine grand rounds this morning which was exactly like surgical grand rounds: 5 minutes of useful information embedded in 55 minutes of sleep-inducing information that is useless to everyone except for the person in charge of the research.

One of my two patients is an 81 year old woman who has been on peritoneal dialysis for the last year (peritoneal dialysis is dialysis that consists of injecting the dialysate directly into the abdominal cavity--the abdominal wall acts kind of like a filter, then the dialysate is drained back out). She came into the hospital over the weekend with an umbilical hernia which she had repaired--she now needs to be on hemodialysis (the patient's blood is sent through a filter and put back into the patient) for a month. I find that I am much more interested in her from a surgical standpoint than a medical.

Nephrology

2007-09-05T15:01:00.000-07:00

I have finished the breast disease rotation. Nothing particularly interesting happened the last few days except that I missed a really interesting operation because no one told me they decided to operate on Friday instead of this week.

I got a three day weekend, and started nephrology consults yesterday. As a consult service, we basically just give advice, so we are not responsible for writing orders, dictating discharge summaries, etc, which means it is a pretty easygoing rotation. They do love rounding though--fortunately, the attending also likes teaching so I am learning instead of just tagging along with a team whose attending does not even make eye contact with the students (rare, but it does happen).

Last night I submitted my residency application--once submitted, one can no longer make changes--it was a little nervewracking. Now, I will be obsessively checking the website to see who was downloaded my application (so far about half of the programs). My last letter and transcript have not been uploaded to the site yet though.

Accessories

2007-08-28T15:12:00.000-07:00

The last two days I have been at clinic. The most interesting patient was a 19 year old who came in for "lumps in the arm pits". I went in to see her--she was seven months pregnant, and had a mass under each armpit which had been swelling and becoming more painful every since she became pregnant (this is her first pregnancy). She had never had swellings like this before, and each day the masses could be soft and mildly tender, or hard and so painful she couldn't rest her arms at her side. She had no medical problems, specifically no history of breast disease, and no one in her family had a history of breast cancer. On exam, she had a tennis ball shaped and sized mass hanging from the underside of each arm in her armpit. They were very soft to touch, not like lymph nodes, and they were tender to palpation. She didn't have any breast masses/pain/discharge, but I did note she had an extra nipple on her right breast (when embryos develop there is a milk line that runs essentially from the axilla down the chest to the abdomen, and nipples/ductal tissue can form anywhere along the line) which I thought was interesting but didn't make any connections. I was totally stumped. I went to talk to the nurse practitioner who immediately realized that the swellings were actually extra breast tissue that had developed in the woman's arm pit. When we looked closer one of the masses did have what looked like a very small, poorly developed nipple. As the woman's breasts have been swelling with pregnancy, the extra breast tissue did as well causing a lot of discomfort. Unfortunately, since she plans on breast feeding her infant, she's going to have the pain for quite a while. Once her infant is weaned, she can see the surgeon and have the extra tissue removed to avoid this with successive pregnancies. The NP told her not to be surprised if she finds milk leaking from her armpits once the baby is born.

On a totally different note, my pastor is starting a Sunday School series on courtship/marriage. To start the series, last Sunday he read the following article: Let's Have More Teen Pregnancy. The author's premise is that society's opinion today is that people aren't mature enough to get married until their late twenties, a belief she finds ridiculous. She talks about the benefits of marrying young (18-20) and uses as an example the fact that she is 49 and has 4 grandchildren already. I don't think I agree with her premise however, at least in my circles, singles in their twenties are single because they haven't met someone they want to marry, it has nothing to do with not believing that they are mature enough for marriage. The vast majority of singles I know desperately want to get married, and most of their families want them to get married too.

Time I'll never get back...

2007-08-26T14:26:00.000-07:00

Wednesday I scrubbed in to the bilateral mastectomy (to clarify the woman's history, she did have radiographic lesions in both breasts, and she had three female relatives who had bilateral breast cancer in their 40s or 50s) and a lumpectomy. The surgeon I primarily work with on this rotation has something of a drill sergeant type attitude, which (thankfully) he does not use on the students (since we're not expected be competent), but increases in intensity toward each successive year of residency. Pretty much the entire case consists of his--not really "yelling", per se--loudly criticizing the resident's technique. Which I'm sure is fairly effective, but does leave the resident rather drained by the end of the case and me feeling pretty awkward having just seen my senior by six years treated like a three year old in front of a room full of nurses and techs. What fun I have to look forward to upon graduation! The next day I scrubbed into another mastectomy with a third year resident--there was still a lot of criticism, but only at about 50% of the intensity compared to the day before with a fifth year.

Friday had one theme throughout the day: inefficiency, purposelessness, and wasting time (I guess that's three themes, but they're all pretty synonymous). Normally, as I have joyfully described in the past, on Fridays I go in for an hour to the pathology lab then have the rest of the day off. However, the nurse practitioner told me the day before that there would be an interesting patient with a good exam at 11:00. So, after pathology I went to clinic. It turned out to be a different patient, but I saw her anyway. When I went into the room she had barely started filling out the five page form all new patients fill out, so rather than come back, I just went through it with her. Which was a mistake, because she kept going off on tangents--twenty minutes later I was getting nervous as this was the nurse practitioner's last patient of the day and I'm sure she wanted to go home. I managed to get all the information and in the interest of time decided to wait on the exam for the NP so we wouldn't be delayed by doing it twice. I got the NP and came back into the room--and was told by the patient she'd rather I not be in the room. Now, I completely understand this, and am actually surprised that so few women mind having a male student doing the exam (she was the first patient the entire month who asked that I not be in the room), but could she not have told me this 45 minutes earlier when I went in to talk with her? So, I waited in the workroom for the NP so we could discuss her case...and didn't leave until 1:30. Basically, three hours in which I learned absolutely nothing and could have been home, or studying, or working out, or etc.

But it gets better. I went to the mall that afternoon to buy a book from Barnes and Noble, and was accosted mid-mall by a man doing a taste test for flavored water. Being the nice guy that I am, I agreed to give him my time and answered his many questions: yes I drink soda, no I don't drink energy drinks, etc, etc, no, I would not buy flavored water based off the advertisement that it "has vitamins and minerals" (I was hoping he would ask me to explain why I wouldn't as I had a great 5 minute response on playing on people's gullibility ready, but he didn't ask). Then he asked for my address which I told him I wasn't comfortable giving, and forestalled his next question by telling him I wouldn't be handing my phone number out either. He wasn't sure how to handle it, and went off to find his boss, and I was then told that I wouldn't be able to participate (yes, I was crushed). Ten more minutes of the day wasted.

Lastly, I have to make a page for my school yearbook. After an hour on the computer last week during which time my computer, Damocles-like, was inches away from being thrown forcefully through the window into the busy street below, I decided that I will simply be giving the publishing company my photos on a disk and letting them arrange them as they see fit. However, I have to have hard copies of my portrait to give to my school. I put them on a disk and took them to the local drug store which I had heard had an uploader machine on which one could edit and crop digital photos. After twenty minutes of frustration in which the uploader machine decided that it could only read the photos I wasn't interested in, the several employees who tried to help me decided that I either needed to make a new disk or use their website. So, I went home, and went on the website, and three minutes later had my portrait cropped and ready to be printed. Grrr.

Saturday morning I went to the free clinic. I saw two patients with the typical hypertension/diabetes/hypercholesterolemia picture. I was able to manage their issues on my own, so the doctor just signed off on my notes and prescriptions without seeing the patients (one of my favorite things about the free clinic is that as a fourth year I get to play doctor). The other patient was a 21 year old guy with a small abscess on the back of his neck. I was getting excited about the chance of incising and draining it, but then the manager told me that we didn't have the equipment so would have to refer him to a general surgeon who sees uninsured patients. Oh well.

Clinic

2007-08-21T15:53:00.000-07:00

Yesterday and today I was in the breast surgery clinic. Yesterday was all follow-up patients (women who have had surgery anywhere from two weeks to 15 years ago and are just coming back as a precaution). Today was a half day in which I saw a couple follow-up and one new patient. The new patient was a woman in her early eighties who had the first mammogram of her life last month. Aside from having a hysterectomy and radiation for cervical cancer a few years ago, she has not seen a doctor since her last child was born almost 60 years ago. The mammogram unfortunately found a small mass that was biopsied and found to be invasive lobular carcinoma. Fortunately it is very small and very low grade. She will need to have surgery and hormonal therapy, but the prognosis is very good.

We were again running late, so despite the fact that the last patient was scheduled for 11:00 I didn't leave until after 1:00 (yes, I do have a taxing schedule this month:). I then went to the library to update my PDA since the program that lists all the drug dosages I will ever want to look up has been dead for the last month and a half. Since I hate dealing with little things like that, and since "procrastination" might as well be my middle name, I waited until today to get it straightened out. It was as bad as I expected. I spent at least 45 minutes in front of the computer getting the wretched program loaded on.

I've spent most of the afternoon working on my yearbook page and I have come close on several occasions to ripping my hair out from frustration trying to do it on the computer. I think I am going to end up just turning in printed out photos and letting the publishing company deal with the mess.

Tomorrow I will be in the OR. The morning will start with a bilateral mastectomy--to my surprise, my brief perusal of the patient's chart indicated that she had very early stage cancer in one breast which is usually treated with a simple lumpectomy and radiation. Bilateral mastectomy seems like major overkill to me--the only thing I can think of it that she was found to have the BRCA mutation which greatly increases the risk of women (and men) developing breast cancer--I'll have to look through her lab results tomorrow. She will have reconstruction immediately after the mastectomy which plastic surgery will do. A similar case yesterday started at 9:30 am and ended at 11:00 pm (plastic, transplant, and cardiothoracic surgery are all specialties I plan on staying away from based simply on the case length--I like them less than 3 hours--then again, I imagine that time would go by faster if I were actually performing the operation rather than standing for hours with my arms extended at incredibly uncomfortable angles holding tissue back so the surgeon can see what s/he is doing).

New link

2007-08-18T08:30:00.000-07:00

I highly recommend visiting the new link in the sidebar, Tominthebox News Network. I've been going through their archives--they are hilarious. Here's a sample post: Fake Rapture. On the more serious side: Doctor.

Edit: And here's another one. I was almost in tears from laughing: Baptism for the dead.

Tumors

2007-08-17T13:42:00.000-07:00

Monday the head breast surgeon came back from vacation for a full day of clinic. All of the patients were follow-ups, having had breast cancer anywhere from a year to 15 years ago. There was nothing particularly striking except for the fact that for a number of reasons we were running at least an hour late the entire day--since we only had 1-2 exam rooms available as the medical and radiation oncologists were hogging the rest for consults the patient flow was very slow and there was a lot of sitting around twiddling thumbs on my part. I did get several questions I had answered by the surgeon though, so altogether it was an educational day.

Tuesday I returned to radiology. Looked at a bunch more mammograms. I was supposed to watch a mammogram being performed so as to understand the different positioning methods, but the techs never came to get me (likely because they had much more important things to do than baby-sit the med student) and I have to admit I didn't use a lot of initiative to make it happen as I could have. I figure there will be plenty of times in my career I'll have to interpret mammograms, and not many times that I'll be responsible for setting up the machine. One amusing point was when I went with the radiologist to ultrasound a potential tumor--the tech was convinced that the patient was hispanic, but knew that the translator who was scheduled to come by had just been interpreting for a Russian patient earlier in the day--she came to the conclusion that the translator must be fluently trilingual, and we were all duly impressed. Until we went into the patient's room and found her to definitely be speaking Russian. The tech was quite embarrassed.

Wednesday was OR day--another lumpectomy. This patient ended up having to spend two nights in the hospital, mostly for pain control, but she was also somewhat complicated in that she had a very rare genetic neurodegenerative disorder. I saw her this morning as she was getting ready to go home, and she was very happy to be leaving.

Thursdays the nurse practitioner usually has clinic, but she is currently on vacation, and the radiation oncologist was taking an administrative day, so I thought that I might get the day off. However, the surgeon had two patients to see in clinic--one at 0830 and one at 1300. The first patient (who naturally wasn't roomed until about 0900) was a woman in her early 30s who had just been diagnosed with breast cancer and was here to discuss treatment options. She and her husband were handling it quite well. Cancer had already spread to at least one of the lymph nodes in her armpit, and she will likely have to have chemo for several months before having surgery. Fortunately, her prognosis is quite good. She is also one of the first patients I have seen who will need an MRI as her breasts are too dense to see anything on the mammorgram. She will also need a full PET-CT to make sure the cancer hasn't spread anywhere else in her body.

The later patient was also a rather sad case, a woman in her 80s who had had a left mastectomy in the 1970s. She was unfortunately somewhat demented and lived in a nursing home. Her attendants had discovered a mass in her right breast a couple months ago. She herself was not even aware why she was at the doctor's, and the daughter who came with her was not the power of attorney, thus I was not able to get a good history. At this point, she had already had a biopsy which showed cancer. In her condition she was clearly not a candidate for either chemotherapy or radiation. When I did the exam, however, it was immediately apparent that something needed to be done soon. She had a huge lobulated mass that filled the lower half of her breast, and the skin on the underside was a dusky blue, indicating that the mass was well on its way toward ulcerating through the skin. She also had readily palpable nodes in her armpit. She will need to be scheduled for a mastectomy and axillary node biopsy within the next couple weeks. Odds are that the cancer has already spread, but it is possible that the surgery may catch it early enough.

Today I was in pathology. I went through several slides with the pathologist, then watched a tumor being processed by one of the techs. Now I need to work on my list of residencies I will apply to.

Random

2007-08-11T08:50:00.000-07:00

Not much new here. I am currently procrastinating studying and residency-applicationing by internet surfing. I came across a real gem: a fish empathy quilt. It looks like something I would make as a joke, but these people are actually serious. I was cracking up looking at it--I found the square that used "WWJD" to imply that Jesus would not "torture" fish to be especially intriguing, particularly considering the fact that Jesus' best friends were fishermen. Idiots. If you're going to argue a ridiculous position, at least use arguments that support your position rather than destroy it. While I found the whole thing amusing, it also really ticks me off that there is so much human suffering and immorality in the world, but rather than address that, these buffoons spend there time making "empathy quilts" for fish! Get a life!

To further procrastinate, last Tuesday while I was in radiology, staring at mammograms for hours on end, with nothing more than a far-too-small-cup of coffee to sustain me through the crushing dullness, I thought to myself: "At least this is better than rounding." A small comfort, but a comfort nonetheless until I remembered that I will be on nephrology next month and have been warned that the nephrologists here love rounding like most people love hot fudge sundaes. Brought down by thoughts of portending doom, I decided to express my feelings in a poem--a poem of the modern variety since I do not like modern poems thus feel a modern poem will express my disgust with rounding more effectively than a rhyming poem with syntax and meter. I'm actually making it up as I type, so I'm not sure how it will turn out--I just know that I will die at the end with a small hint of irony.

Death by Rounding:
Rounding, rounding. Pre-rounding, team rounding, attending rounding.
I think I will die.
I have been in the patient's room for fifteen minutes that seem like an eternity
Nothing is being done
I have long since ceased to hear words and now only hear a humming sound
From the attending's perpetually moving lips
Annoying, yet strangely sleep-inducing
I am drifting off the hospital whirls around me
I think I will die.
Left the room the attending turns to me
His lips move but I can't make out the words
It is a question but I don't know what
I don't know I say in a false cheerful voice but I'll look it up and get back to you tomorrow
Knowing full well that tomorrow I'll be dead. Dead from rounding.
We move on to the next room five hours down and still ten rooms to go
I muse to myself and wish Dante were alive now
The Inferno would have turned out differently
A new circle of hell probably between the sixth and seventh maybe six and three quarters
Would be rounding always rounding
I think I will die.
Ten fifteen forty-three minutes we start to leave the room and the patient asks a question
The same she has asked for three days in a row and gotten the same twenty minute answer
Every Time
I feel it now
Like a dark black cloud settling over my brain
My vision dims
The outline of white coated residents darkens
They become a row of shadowy specters watching me silently
They see death and respect it
The window is the only light object left and I feel myself moving towards it
As my body collapses to the floor like a scarecrow knocked off its pole
By the wind
With my last breath I hear the team and strangely the patient debating
Is the proper terminology
Death by roundosis or hyperroundosis?

Breast Disease

2007-08-09T15:19:00.000-07:00

My rotation is going well. It is very laid-back, and has its moments of boredom, but I am learning a lot. Friday I went to the pathology lab and went over breast cancer slides under the microscope with the pathologist from 0930-1030. Then I went home:). Monday I went to breast surgery clinic with the chief resident and a nurse practitioner. The NP mostly sees follow-up patients after surgery, so I didn't see any tumors. Tuesday I went to radiology--I spent the first three hours (literally) reading about mammography standards and categorizations in a dark corner of the dark room. After lunch I looked over mammograms with a radiologist. Wednesday there was only one breast case which was scheduled to go at noon--I kept calling the OR from home to make sure it wasn't going to go early, then just went in at noon. Then I proceeded to stand around the recovery room until 1330 when the case actually went. Toward the end of the case (lumpectomy with sentinel node biopsy), when I was looking forward to going home for a few hours before going to Bible study, a senior resident walked in and asked if he could steal me from my senior resident--for a thyroid case (they don't have a senior student and all the junior students were in lecture). Muttering darkly under my breath, I said I would be happy to, and one hour later scrubbed in on a thyroid lobectomy. It was actually interesting, especially since I have never been in a thyroid case before, and I was only 10 minutes late to my Bible study. This just reiterates what I have long held to be true, happiness in surgery is very dependent on expectations. When I have been on serious surgery rotations, and came to accept the fact that I would be in the hospital for looonnnggg periods of time, I could stay until two in the morning and go home not feeling ill-used. On the light rotation that I am on now, if I am in the hospital later than 1600, I get all bent out of shape.

I'm back...

2007-08-01T13:47:00.000-07:00

So I've just ended my month off. Trauma surgery ended well, it's the first rotation I've been on that I've woken up early the next morning and thought that I wouldn't mind doing it for another month. Since I was on call June 30th I didn't leave the hospital until July 1st therefore I got to see the new interns--very weird to think that I will be in their position in less than a year. I flew home and enjoyed two weeks with my family away from my place of exile, then returned to take step II. The written exam was 9 hrs long, by the end of the day my eyes were glazed over and I would regularly jolt out of a stupor and realize that I had been staring at the same question for several minutes--fortunately I managed to finish each block within the hour time limit. Now, thankfully it is over...hopefully I won't have to take it again! Monday I went to take the clinical skills section of step II, which is a total joke--it's fairly pointless and took $1000 out of my pocket (I will stop my criticism here as I tend to get extremely heated and long-winded when I get going on this topic). Also, no matter how good the actors are, they are still actors in clearly contrived situations, and they respond like actors with a script, not like real patients. ("Have you noticed any blood in your stool?" "No, doctor [yes, we were addressed as "doctor" throughout the day], there has been no blood in my stool and my bowel movements are regular"). Naturally, even though the scenarios were fairly simple (and I have far too much respect and healthy fear for the USMLE people to give any examples whatsoever) I still managed to forget key questions to ask on virtually every patient, then remembered them as soon as I left the room (once you leave the room you can't go back in) so thus spent much of the day mentally kicking myself.

Today I started my month of breast disease--in a way I am glad to be seeing patients again, but at the same time last month I grew accustomed to a certain standard of living (get out of bed whenever I want, play online for as long as I want, etc, etc) that I am somewhat loath to give up. Fortunately, this is going to be a fairly light rotation. I will spend days with surgeons in clinic, surgeons in the OR, radiation oncologists, radiologists, and pathologists to see breast disease from all aspects. Today was an OR day--there was only one case and it was scheduled to follow an I&D around noon. So I got to the hospital around 1100, only to find that they had switched the cases and started with the lumpectomy at 1000. Fortunately, the surgeon and resident realized that there was no way I could have known since I wasn't on service in the hospital--the resident hadn't known until five minutes before the case started. (The reason by the way that I chose to do a month of breast disease [which I feel obligated to tell every non-medical person I know without even being asked] is because the breast surgeon is also the program director, and thus is a desireable person to a) get to know since I could very well be ranking this program highly in the match and b) write a letter of recommendation. Also, breast surgery is a fairly significant part of general surgery so it will be good for me to be familiar with anyway.)

The main thing going on in my life now that boards are over is getting my residency application ready. So far I have written the rough draft of my personal statement, entered most of the necessary information into ERAS, started making a list of programs I will apply to, formulated my CV (pathetically short and unimpressive) ,and met with the chairman whom I had never even seen before to ask him to write me a letter of recommendation (he will by the way). I still have to polish my personal statement, meet with my advisor to talk about programs and ask for a letter of recommendation, meet with one of the deans to discuss the dean letter, do well on my current rotation so I can meet with the program director and ask for a letter of recommendation, and...I'm sure there are several other things that I am forgetting at the moment. I despise the application process and have been dreading this since I started medical school. I don't despise the paperwork half as much as I despise interviewing however, so I've got a long way to go yet...

Coming to a close

2007-07-03T11:52:00.000-07:00

Only one more day of trauma surgery left—although it is a call day so I won’t actually be done until the morning of 7/1. We have been really busy the last few days, but I have been in the OR most of the time so have missed most of the traumas that have come in. I haven’t seen many consults either. My last call night I was in the OR from 10:00pm until 4:30am with 5 successive cases. One of the cases was an elderly lady who had not seen a doctor for 30-40 years (she is very into herbals) who had classic cholecystitis. I saw her in the ER in the morning—the residents were swamped, and since this was definitely not an emergency (our initial plan was to not operate) it took a while for them to see her. I got stuck in the ER seeing a couple other consults and every half hour I got paged by the ER resident taking care of the first patient who then tried to harass me into getting things moving faster—it was really annoying, I can see now why there is sometimes tension between different medical services, though I can’t imagine that he would have had the nerve to multipage anyone other than a student. Two of the times he paged me I was in the room talking to the patient, the second time my senior resident was there trying to admit her. We were going to admit her and just give antibiotics then take her gallbladder out next month (since she was old and hadn’t seen a doctor for decades we had no idea what her cardiac status was), but she worsened throughout the day so we had to take it out—we weren’t able to until about three in the morning though.

Today I got to I&D a shoulder abscess by myself—it was pretty fun though I felt bad for the patient. I’m not sure if he was demented or just delirious, but his cognitive function wasn’t all there and he was totally deaf which made it hard to explain what we were going to do. He had an abscess about the size of a golf ball on his right shoulder, so we numbed it up, then I incised it with a scalpel—there was a lot of pus that I had to squeeze out, then I had to stick my finger in the pocket and break apart the loculations. Then I packed it with a strip of sterile packing which will be removed in a couple of days.

Later in the afternoon we had a patient whose small bowel was completely obstructed by a large dermoid tumor on one of her ovaries (dermoid tumors, which I think I have written about before are benign tumors that can be made up of virtually any tissue—hair is a common one). We opened her up, and moved her ovary away from the bowel, then the Ob/Gyn doctors came in to remove the tumor—it was huge—the exact size and shape of a newborn’s head, the operation looked like a c-section. I kept expecting to see a face on the tumor. Once they got it out they cut it open to reveal a matted hairball immersed in gooey yellow liquid—so disgusting. The whole case reinforced that I am not a budding gynecologist.

Last week the senior residents rotated so we now have three new seniors, all female. It has been a big improvement—they are extremely conscientious of their subordinates’ working hours and are extremely good about getting people out of the hospital. We have been going home between 5:00 and 6:00 this week instead of between 7:00 and 8:00, even though we are just as busy as before. It’s amazing how just getting one or two extra hours of free time in the evening can be so beneficial to one’s lifestyle.

New record

2007-06-18T18:12:00.000-07:00

This week I broke one of my records without even realizing it until I did some calculations this evening—I worked at the hospital 98 hours this week, shattering my previous record of 90 attained on CT surgery last year. I had to add it up several times before I believed it—100 hour work weeks are much more doable than I ever thought possible.

I have seen so many traumas this week that they have started to run together in my head. The most dramatic was a man who was brought in unconscious after a gun shot wound—we did a rapid assessment, then rushed him to the OR. We cracked his chest as he lost his pulse—I did chest compressions for about five minutes while the surgeons attempted to control his bleeding (he had lost almost two liters of blood from his chest before we got him to the OR, and was rapidly losing more). They found the artery, but it was too late and he died on the table, a sharp contrast to the man last week who lived.

The most memorable was at about 10:00pm when we got the page: “man fallen on by cow”. He was unconscious when he came to us so we weren’t able to get the full story. Amazingly all he had were a couple of cracked ribs, and he woke up the next day, and went home the next. I was able to get the story before he left: apparently a cow had bumped him and made him trip over a feeder, another cow then ran into the first and it tripped over the feeder onto the man’s chest—he is very fortunate to have escaped with such minor injuries.

One nice thing about level one trauma centers is that they tend to be very organized, and they operate on a protocol. When the patient is brought into the ER by the paramedics, he is immediately transferred to the hospital gurney, then the paramedics remove their gurney. The patient is surrounded by an number of doctors and nurses, the doctors are residents from either ER or surgery depending on the week. The captain stands at the foot of the bed and directs everyone. Doc Right stands on the right and performs the physical exam, starting with ensuring adequate breathing and pulses and then moving to less vital areas. The head doctor stands at the head and controls the airway, intubating if necessary. Doc Left (usually a medical student) stands at the left and cuts off all clothing as soon as the patient arrives to expose any hidden injuries. If the patient is rolled away from him while removing the backboard he also checks the back and does the rectal exam. Later, he draws blood from the femoral artery and places the foley catheter if necessary. The attending surgeon stands in the back of the room and makes sure no one screws up. For each doctor there is a nurse who gets vitals, obtains IV access, and performs other duties. If the patient is stable he is then taken to the CT scanner. Depending on what is wrong, he either goes back to the ER, to the ICU, or to the OR.

My last call night I saw the call rooms (room with a bed, desk, and telephone for residents/students to sleep in during down times) for the first time this rotation. Around 1:00 AM I went to bed, but unfortunately it was just a tease—ten minutes later as I was just in the transition zone between sleep and wakefulness another trauma came in. An hour later I went back to bed, and this time managed to fall asleep and stay asleep for 45 minutes before being rudely awakened by (one of the three that I carry on this rotation) pager. When I called back, it was the ER who had a man with a large perineal abscess—why he felt the need to come in at 3:00 in the morning instead of the next day I do not know, but I was pretty annoyed. I went to see him, then paged my poor intern, waking him up as well. It turned out all right though, because three minutes later we got another trauma so we would all have had to have gotten up anyway. This trauma was an assault victim. Five minutes later we got another assault victim. It turns out the first had tried to stick up a bunch of people, and had gotten beaten up for his trouble. The second was one of the people being stuck up who fought back. Fortunately we only admitted one to our service so we did not need to have police guards at both rooms to keep them apart.

Death's Door

2007-06-12T18:41:00.000-07:00

Trauma surgery has rapidly become one of my favorite rotations. Despite the 14 hour days interspersed with 30 hour call days I find that I am not dying to leave by the end of the day like most rotations I've been on--I've even managed so far to successfully get out of bed at 4:30 (though historically I tend to get up progressively later as the month goes on, starting with getting to the hospital easily ten minutes early and ending with running into the workroom out of breath several minutes late). My most recent call day was Sunday/Monday and it was nuts from 7:00 AM until about 4:30 AM. The first consult I saw was in the ER, a man who had been on a riding lawn mower and made too sharp of a turn which caused the mower to rear up and flip over backwards--fortunately it did not land on him, but his thighs were covered with gasoline just before the mower burst into flames, which made him burst into flames. His inner thighs were totally burned and covered in huge yellow blisters. Fortunately for him the burns were mostly superficial, and we just dressed him with antibiotic cream, gave him fluids, then sent him home the next day with a healthy supply of narcotics. I wrote admitting orders for the first time, which ended up being quite a mess with things crossed out and sentences being continued several lines from where they started, but on the plus side my handwriting is actually legible which is more than can be said for a lot of doctors (but before anyone jumps on the doctor=bad handwriting bandwagon, a study was recently published which showed that doctors' handwriting is actually no worse than any other professions--the only group that had significantly worse than other professions' handwriting was male CEOs).

The next consult I saw was a man with a left buttock mass that had been growing for years--likely a hematoma as he has hemophilia. When I got the consult I was expecting a fair sized lump, but when I went up and saw him...wow. I have no idea how he functions at home. "Massive" was how it was described by the internist in the chart and I can't think of a word that better describes it (at least that one could write in a chart--"ginormous" might not be considered quite professional). I left before I heard the plan for him, but my guess would be that they'll recommend follow-up as an outpatient (he came into the hospital for other problems).

Around 10:00 pm we had a stab wound to the right flank come in. We took him to the OR for exploration, he was fine. As we were closing him, we got a call that a gun shot wound patient was coming in. The resident and I stayed to close while the attending went down to see the new patient. They rushed him into the OR, and as soon as our first patient was closed the resident left me to see him back to post-op and went in to the GSW case. I came in a few minutes later--they opened him up, and found a lot of blood in his abdomen. They searched around for a while (the patient was literally dying on the table at this point) and finally discovered that the bullet had shattered his left iliac vein--yet had somehow missed the artery that overlies it. At this point there were four doctors surrounding him, so I couldn't see everything clearly, but it was the most intense operation I've seen yet--I wasn't very optimistic as to his survival. Amazingly (and providentially) they were able to repair the vein and I went and saw him this morning. His only complaint was that he was a little sore.

The highlight of today (though very tragic) was an 18 year old with a self-inflicted gunshot wound to the head. In the ER they stabilized him with IV fluids and intubated him, then we rushed him to the CT scanner, then rushed him to the ICU. His pressures were practically nothing, and his pulse was very high indicating hypovolemic shock secondary to bleeding out through his head; several attempts were made to place IVs, and finally they just put a central line in. This unfortunately is one of the cases where despite hours of working on him, most likely it was all in vain--he had brain tissue coming out of the bullet holes which is not a good prognostic indicator.

Trauma call

2007-06-06T16:14:00.000-07:00

Yesterday/this morning was my first call day--so much better than the other two days I've had. The student on call carries the consult pager which gets all consults from the floors and from the ED, as well as all the incoming traumas and his/her primary responsibility is going to see those patients rather than going into the OR or working in clinic. I saw a bunch of consults. One was a lady consulted to us by medicine who was discovered to have a hard lump in her abdomen--it ended up being mesh from a surgery 15 years ago, and now that she's lost weight it's palpable. There was a young man with a groin abscess in the ED whom we took to the OR for drainage (there was a lot of pus!). There was a lady with breast pain and drainage in the ED (6 months after having nipple ring removed)--she had a mass but not enough to be drained, so she'll get antibiotics for a week. Another was a lady with right lower quadrant pain x 1 day in the ED--CT scan couldn't rule out appendicitis, so she was posted for diagnostic laparoscopy. However, before we could take her to the OR we had a trauma come in. A youngish man had been waterskiing and somehow got his left arm caught in the tow rope handle, fell, and was dragged by the boat by his arm pit. He went to an outside hospital, then came to us three hours later. His arm was huge and tense, and we could not find any pulses by palpation or ultrasound. CT scan showed an open artery until about halfway down his upper arm, then it disappeared. We took him to the OR (the possible appendicitis lady wasn't critical)--it was probably the bloodiest (at least initially) operation I've yet seen. As soon as the resident made the incision about 1-2 quarts of blood streamed out covering his gown and the table in blood--the patient's arm looked like a deflating balloon. When they lengthened the incision we discovered that his biceps muscle had avulsed from it's point of insertion in the upper arm, had flipped down into his forearm, and was now hanging dead from his elbow. His main artery and vein were completely transected and he had a lot of nerves hanging around though his median nerve was intact. The vascular fellow and the resident harvested the patient's saphenous vein from his leg and grafted it between the two ends of the severed artery. They removed the biceps muscle and closed. The attending had me close the subcutaneous tissue of his leg which was very neat--the first time I've ever sutured more than skin. Plastic surgery will have to take the patient to the OR this week to see if anything can be done about his nerve damage. Unfortunately, the vascular surgery attending told me the patient even now has a 50% chance of losing his arm.

We were busy until about 0330, then I had to update the list. By the time I was done it was 0400, and since everyone else was coming in at 0530 there wasn't much point in going to bed. When everyone came in (there's something very cheerful about having the rest of the team come in after only having three people doing everything all night) we rounded on patients then went to Morbidity and Mortality (residents present cases in which something bad happened to a patient and attendings grill them mercilessly and yell at each other about what could have been done differently--though today was pretty tame, they must have been tired) and Grand Rounds. I then helped get all the morning labs, and at 1000 after working for 28.5 hours straight I went home and slept for 6 hours--it is odd how without using an alarm clock I always sleep for almost exactly 6 hours after being on call.

Trauma

2007-06-02T12:16:00.000-07:00

Family medicine ended Thursday. It was a good rotation, and also the last of my third year:). Yesterday I began my final year of medical school with my surgical sub-i, trauma surgery. Sub-internships are rotations for fourth years in which one theoretically acts as a "highly supervised intern" but without having any actual authority or order-writing ability--I say theoretically because on this particular rotation there are few and scarcely detectable differences between the duties of the sub-i and the regular third year student (both of whose jobs can be summarized succinctly in the word "scutmonkey"). So far the only difference has been that in the two days of clinic per week, the sub-i sees the patient and staffs directly with the attending, while the third year supposedly staffs first with the resident though in reality they also usually staff immediately with the attending. Another difference is that the sub-i's carry a special pager for nursing questions, though as of yet it has never been paged, no doubt because the nurses find it pointless to page someone who doesn't have the authority to act on the problem--but again, it's only been a day, so this could change.

My team consists of three interns, three senior residents, multiple nursing practitioners, three third year students, and one other sub-i besides me. And of course the group of attendings who supervise. Blurring the distinction between third year and sub-i even more is the fact that the third years are in my class and therefore have as much patient experience as I. My school's third year schedule provides one month of vacation--I was fortunate enough to have mine be June, which gave me the ability to postpone my vacation month until next year, and start 4th year early, which means I am doing the rotation with third years who had their vacation months earlier in the year and therefore are still finishing their third years and will not be fourth years until July.

Students' duties primarily consist, as I alluded to before, of scutwork (scutwork by the way for those not familiar with the term [is it used outside of medicine?] is work that is very necessary, but falls to the bottom person on the totem pole and provides absolutely no educational value or benefit whatsoever to the person performing it, and usually is something which could be done easily by a drunken chimpanzee) such as keeping the patient list updated (and there can be up to 70 or 80 patients on our team), writing down morning lab values for said patients, and writing down the final radiology reports for all trauma patients for the interns--basically the duties of a glorified (or degraded, I think I could argue it both ways) secretary except we pay them to let us do the work rather than the other way around. Fortunately, I was warned before about this, so I was somewhat prepared for this. The trade-off is that we should be able to see a lot of really neat stuff. In between scutwork yesterday I saw a urology consult--a 60 year old woman who had her bladder removed last year due to transitional cell carcinoma, and now has a urostomy bag for her urine similar to a colostomy bag. She was admitted because an outside hospital had found a large mass in her pelvis by CT scan, and one of their surgeons did an exploratory laparotomy (incision) and found stool in her peritoneal cavity (bad sign as it should be confined to the colon)--a biopsy found recurrent cancer (very, very bad prognosis unfortunately). However, now she has stool literally oozing from her incisional wound. She will need a study to make sure that only her colon is perforated, and if so, she will need a colostomy. After I saw her, the resident and attending apparently re-opened her incision, drained more than a liter of stool, and packed the wound (at this point I was back to scutwork:).

Tuesday will be my first call night (fortunately since we have five students we will be on call only every fifth night instead of ever second or third as has occasionally happened in the past and we get weekends off unless we are on call which means I get two golden weekends which is two more than I had anticipated--unfortunately my last call night is June 30th which means I won't leave until the morning of July 1st), it should be exciting.

Family Medicine

2007-05-14T19:10:00.000-07:00

My computer has slowly been dying, and is at last (hopefully temporarily) dead and is now in the shop. Fortunately, the shop owner goes to my church and was generous enough to give me a loaner which I am rapidly becoming quite fond of.

CPR ended well. The last week kind of dragged, but on the positive side over the two and a half weeks I did almost 40 successful intubations. I am now on family medicine which I am enjoying apart from the couple hours a week of problem based learning which I despise. There are only two drawbacks: 1) the clinic is a half hour north of where I currently live, and school is a half hour south, and 2) two days a week clinic goes until 7:00 and one of those days is the day I have Bible study near school at 7:00. To further complicate matters, I am moving to my own apartment near school in a week.

Highlights of the last couple weeks:
1) My mom and one of my sisters came out for a weekend to help me get stuff for my new apartment.

2) I got a beautiful cabinet/bookshelf thing and a brand new leather recliner from an outlet store at 80% off.

3) I got an email from Lippincott telling me that I have $100 credit to purchase books from their website as a thank you gift for reviewing a couple chapters of a new edition of a textbook written by faculty from my school.

4) I saw the most incredibly massive wart that I have ever seen on a girl's hand.

5) At the student run free clinic I saw four patients with a first year student, three of them I was able to take care of myself and the attending just signed off on my note without even seeing the patient. One of them had an HbA1c of 16--by far the highest I've ever seen (normal is 5-6ish). Another had a flushing reaction to her niacin and was absolutely convinced that it was due to her multivitamin despite my telling her that flushing is an extremely common side effect of niacin and my bringing up the fact that the flushing took place 10 hours after taking the vitamin and minutes after taking the niacin.

6) I finished the currently written George RR Martin books--unfortunately I can't recommend them. While they are extremely well written, and have intriguing plots, he delights in filling them with all kinds of obscenity.

7) I started reading several of Bram Stoker's books. The Jewel of Seven Stars was quite good, I read it in one sitting, Lair of the White Worm was a little confusing. I'm about a third of the way through Dracula and so far it has been the best of the three. On my last foray into Barnes and Noble I bought "Jonathan Strange and Mr. Norrel" by Susannah Clarke which looks like it will be good. I had never heard of it before, and I have to admit one of the main factors in my deciding to buy it is because it is an 800 pg hardback that was on discount for $7 and it will look very nice on my new bookshelf in my new living room.

8) We had the dinner for the graduating seniors of the Christian Medical Association on Friday. Interestingly, with one exception, all of them matched into either family medicine or surgery.

Videos and noses

2007-04-21T09:44:00.000-07:00

Yesterday a sales rep for glidescopes came by. The glidescope is a plastic device with a camera on the end designed to replace the standard metal laryngoscope--it was actually pretty neat, but since the anesthesiologists were trying it out it prevented me from intubating people, so I kind of hate it. It is particularly meant for difficult intubations, but apparently some prefer it for even standard intubations since it is gentler on the patient's mouth--one doesn't need to pull upwards on it like one would a laryngoscope.

The highlight of the day was when I successfully intubated a patient nasally. An oral surgeon comes on Fridays, and since he obviously needs to have access to the patient's mouth he can't have a tube sticking out of it. There were two patients, the first I did not succeed on, but I got the second. To intubate someone nasally, you first dilate one of the nares with a series of progressively larger rubber tubes, then you have someone assist by advancing the endotracheal tube through the nose. Then, you use a laryngoscope in the standard fashion to visualize the vocal cords and guide the tube between the cords with a pair of McGill forceps while the assistant advances or withdraws the tube per your instructions. I was very happy, I didn't think that I would even get to try nasally intubating someone, much less succeed.

The nice thing about this rotation is that I feel like a normal person. I don't have to worry about studying when I get home (though that needs to change this week as we do have an exam at the end of the month), and weekends are totally free. Yesterday evening I was going to meet some friends at a park by the lake, and I still had time to spend an hour going through Barnes and Noble beforehand. I bought John Piper's "Desiring God" which looks very good, as well as a collection of some of Bram Stoker's books. I have always wanted to read "Dracula" but never have. I was also trying to find "The Language of God" which apparently is a book by the man who ran the human genome project defending faith in God, though I believe he is a theistic evolutionist and not a creationist. I couldn't find it, but did find lots of books in the theme of "The God Delusion" by Dawkins. I started paging through one to see what the author's arguments were, but had to put it down as I was beginning to visibly shake my head in disgust and was on the brink of actually making loud uncomplimentary comments and as I was standing by myself in the middle of the store I didn't want people to think I was high on something. Also in that vein for a lark I went by the alternative health section and picked up a book by Kevin Trudeau who essentially claims that the government is covering up the fact that all human illness and suffering can be solved by taking an herb--and he does it in the most irritating informercial-style possible. Again, I did not look at the book too long since another minute would have resulted in my flinging it across the store.

I found out my fourth year schedule yesterday. I'm quite happy with it, I got pretty much everything I wanted when I wanted it. The sequence will be: trauma surgery sub-i, vacation/step 2, breast disease (with surgery program director), nephrology consults, away rotation (which I still need to set up), ER (in November, so hopefully I can schedule shifts around interviews), two months of vacation/interviewing, then pediatric sub-i (we had the option of internal medicine, peds, or family; if I could have done internal medicine at the VA I probably would have ranked that first, but since I was at the VA last year my sub-i would be at the school's main hospital, and as sub-is we have much more autonomy at Children's where we really are treated as interns). My last serious rotation will be inpatient cardiology in March, then in April I will have radiology (also known as radiholiday--we have to show up, but have no actual responsibilities), and May will be "Preparing for internship".

More intubations

2007-04-19T17:17:00.000-07:00

So far I have done 20 intubations and still have a week and a day left. Much as I enjoy this opportunity and like the people at this hospital, I think another week of this is really unneccessary. I'm getting a little tired of having no responsibility other than putting a tube down someone's throat four times a day and sitting around playing games on my PDA during the in-between times. On the bright side one of my attendings quickly became my favorite person of the month after telling me that I should not be at the hospital any later than noon on any given day. I can live with that. This week we had lecture every afternoon anyway, but next week we have no lectures. I'm not sure what I'm going to do with all the extra time.

Intubate

2007-04-16T18:55:00.000-07:00

Today was a good day--I stayed busy and held off boredom. I intubated four patients, the last three I did entirely by myself. Last week I couldn't find the vocal cords on my own so the anesthesiologists had to position the blades for me. This afternoon we had three very crummy lectures. The good news though is that I was able to wear a short sleeve shirt outside today! (as opposed to having to trudge through almost a foot a snow and icy winds like last week).

Procedures

2007-04-15T13:06:00.000-07:00

Not much going on. This month I am on a clinical procedures rotation. The first week and a half consisted completely of lectures (some of the days we didn't have to show up until ten!o!clock!!!) sponsored by the emergency and trauma surgery departments on resuscitation and advanced cardiac life support. Now, theoretically, should someone go into asystole, vfib, or vtach right in front of me I'll be able to do something about it. I'm still working on recognizing orthodromic reentrant tachycardias and other such things though.

The last two and a half weeks of the rotation consist of following an anesthesiologist around. Most students go to the main school hospital and are assigned a resident they are with everyday, and are supposed to remain in a case beginning through end. I have the advantage of being at a community hospital where there are no residents and I am the only student, and I am encouraged by the staff to "procedure hop", which means jumping in at the start of a case, intubating the patient, then jumping to another case to maximize the number of intubations I can do. Once I get the swing of things I think it will be beneficial and I should get to do lots more intubations than most of the other students. Right now though it just feels very weird to intubate someone I've never met, then leave before the operation starts. The problem with this rotation is that in between intubations it is unbelievably boring. After two hours I feel like I have worked a full day. Most days next week we will thankfully have lecture in the afternoons, but Friday there was no lecture and I stayed til 3:00. By the end of the day that was the most miserable I have felt this year, I don't know if I could have handled staying another minute longer. But fortunately everyone is very nice at this hospital, and everything just seems so much more relaxed than at the academic hospital. It definitely confirms my desire to be a community surgeon rather than an academic.

In May I will start family medicine in one of the rural areas "near" where I live. It will be the last rotation of my third year! In June I will do my trauma surgery sub-i, from which I will hopefully gain a couple letters of recommendation. I'm going to take July off and will take both the written and (grrr) clinical portions of Step II. Then I'll have to start applying for residencies.

End of psych

2007-03-30T17:46:00.001-07:00

Psych is now over. Next up: clinical procedures. I should get to do a lot of intubating and IV starting—I think we’re supposed to learn how to run codes too.

The family meeting w/ the patient and his mother was postponed as the patient went back into depression because he was so nervous about it. So I’m not going to see what his mother is like. He was going to look at an apartment last Wednesday—right before the social worker was going to take him the apartment called and said they had turned him down because of his criminal record. Interestingly, something that has come up is that his depression and acting out has gotten much worse over the last six months—as his mother’s health has declined. The current hypothesis is that all this rage, depression, and wanting to move away from his mom is due to the fact that he’s actually scared sick of losing her. Another psychiatrist on the ward interviewed him to give a second opinion, and she believes that once the mother dies he is going to be at a pretty high suicide risk, which makes sense, because I honestly don’t think that he can function on his own. He has no friends or family aside from his mom, and she currently does everything for him. Very sad.

In outpatient, I saw a thirteen year old boy with severe ADHD, but more interestingly with enuresis (wetting the bed) and encopresis (passing stool in his pants). The encopresis dates back to when the kid was three years old and being toilet-trained. One day (and this story was confirmed by his parents), at the exact moment he was sitting on the toilet, the boiler exploded, all the water rushed out of the system, and the sudden change in pressure created a suction that literally sucked the poor kid into the bowl! He was so badly traumatized that he still avoids the toilet.

Another patient was a teenager with ADHD and Asperger syndrome, which is similar to autism but without intellectual deficits. Before being medicated he apparently could not sit still, and was constantly doing silly things and making ridiculous comments about everything to everybody. When we saw him, he sat and read “Left Behind” as we were talking to him and the social worker, and every once in a while he would make random silly comments without looking up. Here’s part of the interview:

Psych: How is he getting along with the other kids?
Soc Work: He’s fine. Most of the other kids realize he’s just an intrusive guy and they accept it.
Psych: Right, it’s not like he’s ever mean or anything.
Patient: (never looking up from book) No, I’m just annoying.

More psych

2007-03-22T19:19:00.000-07:00

I’m still at the VA—I’m enjoying it more now that I’ve gotten used to the swing of things. The 63 yo man who lives w/his mother was discharged after being instructed (as he has been for a long time by several therapists/psychiatrists) that he needs to move away from his mother—he planned on doing this eventually, and in the mean time planned to go to a movie/get out of the house when he got too frustrated. He was discharged in a good and optimistic mood a week and a half ago. Yesterday he came back. As soon as he got home, he apparently went back into his depressed/enraged state and spent a straight week in bed without eating or drinking. He pushed his 86 yo mother to the ground. Two days later he tried to slit his wrist and failed, then tried to overdose—though these actions were really more of attention seeking gestures than actual attempts—he barely scratched his wrist and he only took four of his regular pills. He decided he needed to be admitted again, so his mother drove him to the hospital. We are going to have a family meeting w/his mother next week which I am kind of looking forward to—I’m very curious to see what his mother is like. When we discharge him this time it will be after he has found housing that he can go to straight from the hospital.

The 69 yo schizophrenic is still here, entertaining as ever. He’s a very nice man, and particularly happy now that he has off ward privileges. You can actually hold a fairly reasonable conversation w/him now that he is back on his meds, though he still has his delusions and hallucinations. He talks a lot about ancient Egypt, and when we asked if he reads a lot he said that he doesn’t need to because he was born there. Centuries ago he worked there as a builder. He also exhibits “clanging” at times, in which his train of thought follows similarly sounding words. Eg: “I accidentally killed King Tut on purpose, because he took me for granted, granite, what the pyramids were made from”.

One morning a week I go to outpatient at a program for boys who are drug abusers, sex offenders, or have ADHD so bad that their local schools can’t handle them. A lot of very sad cases.

A couple nights ago my Bible study group spent 4 hours blowing up 1000 balloons as a welcome home gift to one of our friends. Above are a couple pictures. Quite impressive I think.

Psych

2007-03-14T14:46:00.000-07:00

I've been on my psych rotation for the last week and a half--inpatient ward at the VA. Unfortunately being the VA there is not a lot of variety, the majority of patients are there for alchohol or cocaine detox. Here are some descriptions of the more interesting patients:

1) 63 yo man presenting with suicidal ideation x1wk. History of depression x30yrs, recent episode triggered by anger at overbearing 83 yo mother with whom he lives--she puts toothpaste on his toothbrush, sets out clothes for him, and "doesn't let him have a life of his own". He wants to move, but can't afford to--he only makes $900/mon and half of it goes to pay legal fees for the dozens of times he has impersonated a police officer and asked people to carry each other (he has spent a total of 11 yrs in prison and 10 yrs in mental institutions for this).

2) 65 yo man who cut his wrist the day before. Doesn't know why. Thinks he felt kind of sad. Wants to go home. Very jolly man w/ possible borderline personality disorder. Made comment at the end of interview that maybe now his wife will want to move to different state as he has wanted to for years.

3) 69 yo schizophrenic man brought in by police for disturbing the peace. The Bantu people of Africa apparently believe that he is Amen-Ra, he can see images coming out of electric sockets (due the actual 6 dimensions as opposed to the 4 described by Einstein), and today he had breakfast with Moses and Aaron. He is actually Jewish although he looks black, and people who say they are Jews but aren't are trying to kill him because he has kindness in his heart and kindness, as we all know, kills. In his spare time he builds $50 million battleships. He's a very pleasant man, and the way he talks I think he could easily start his own Eastern-type religion if he could just keep his story straight.

Saturday Clinic

2007-03-03T12:46:00.000-08:00

Neuro is over. Psych on the inpatient wards at the VA will start on Monday.

Today I went to the Saturday Free Clinic since I finally regularly have weekends off. I saw two patients with a first year student, both were diabetic/hypertensive/hyperlipidemia patients. The first just needed refills (he also had depression) but was also complaining of painful swollen fingers since yesterday. None of us could see any swelling whatsoever, so we told him to take tylenol for pain. The second patient was diagnosed with diabetes five years ago (his brother has heart disease and diabetes and his sister died of diabetes when she was 50) but has been off meds for the last two years due to loss of insurance. Today his fasting blood sugar was 375 and his blood pressure was 162/90. The doctor said in her office she would just start someone with sugar that high on insulin, but in this situation (not necessarily a reliable patient) we just started him on metformin.

Afterwards I took the advantage of being in that area of town and visited my favorite grocery store: Trader Joe’s. I also went by Barnes and Noble. I just finished the eleven currently written books in the Wheel of Time series—unfortunately the series is not finished (similar to the Lord of the Rings the books are all one story), and the author is dying of amyloidosis. Naturally I hope his disease progresses very slowly for his sake, but I wouldn’t complain if he also managed to finish the series in the meantime. George R. R. Martin’s books have been recommended to me by several people as being even better than the Wheel of Time series, so I bought the first four currently written books. On the plus side, to the best of my knowledge the author is not dying of a chronically progressive disease.

Neuro stuff

2007-02-24T13:26:00.000-08:00

Yesterday I was on call (although we were sent home at about nine which was quite nice). Not much happened during the day, but we saw 3 or 4 consults in the ER that evening.

One was an alcoholic who complained of having about 5 seizures an hour for the last day. He didn’t have any while we were in the ER, and his exam was not particularly convincing. He got admitted for seizure monitoring. The next was a woman who has had weakness for the last seven months. She was hospitalized last July for two months then sent to rehab for another two months after some improvement. Her neurologist diagnosed her with Guillain Barre (an autoimmune disorder that usually resolves with time), but now questioning his diagnosis and referrred her to the chairman of neurology at my school. She has an appointment in March, but her husband (who has been her caretaker) had gotten to the point where he didn’t think she was safe in the house. He couldn’t get her into a rehab facility, so he brought her here thinking that the chairman would be able to see her sooner (not correct unfortunately). There was really absolutely nothing we could offer them that she hadn’t received in the last seven months. The resident told them that if they didn’t feel she was safe at home he could admit her and after the weekend have the social workers try to find a facility for her, and the woman flipped out. She started screaming at her husband that she wanted to go home, and that she would die if she stayed at the hospital that night. When the husband tried to tell her that he didn’t want her to fall and hurt herself at home, she started screaming and kicking like a three year old having a temper tantrum. We excused ourselves to let them sort it out. He ended up calming her down and she was admitted. When we left for the night we passed by her room and she was much calmer and apologized for freaking out.

The last patient was a woman with a numb foot for the last day. The ER did a CT scan and chest x-ray (not clear on why the CXR—our resident on being asked made a joke about its being because she walked through the door of the ER), both of which were normal as was expected. The resident thought she had somehow injured her peroneal nerve peripherally.

One of the problems with this rotation is that there are a lot of fakers. The clerkship director told us that half of neurology is weeding out the fakers from the patients with genuine conditions. We’ve already had a couple on our service, it’s making me very cynical.

Neuro

2007-02-21T18:47:00.000-08:00

OB is over. I now have two weeks of neuro, then four of psychiatry.

Today I had the best drug rep lunch I have ever had--he brought beef tenderloin, two types of fried catfish, really good cajun shrimp, really good bread, seafood salad, Asian salad, pasta salad, and a variety of desserts from a gourmet bakery. Afterwards, I stopped by the hospital coffee shop, and the lady gave me free coffee because I had to wait two minutes for her to brew a fresh batch. On the way home, it was warm enough that I cracked my car window (as opposed to the minus 10 that it was last week). Very good day.

Call, call, call

2007-02-08T14:41:00.000-08:00

Last night I was on call again—one more call night to go. In the afternoon I was in clinic. The most interesting (and saddest) case was a 30 year old woman with seven children (from four or five different fathers) who had an abortion in December with her eighth pregnancy. Ever since she has had cramping, and she never passed blood or tissue. She was diagnosed with an incomplete abortion, meaning that the fetus is dead but still in her uterus. She will get an ultrasound today or tomorrow and likely will have a D&C done to remove the dead fetal tissue. She had no suspicions coming in that she had retained the fetus, and was interested in birth control—but she wanted us to be sure to do a pregnancy test first because she thought it was fairly likely she was pregnant again.

In the evening, I was in on one delivery with a family practice resident and attending. The patient pushed for about 45 minutes without anything happening, and the resident failed in two attempts to attach a scalp electrode to the baby to monitor its heart rate. I do not have anywhere near enough experience to know if they were doing something wrong, but it was definitely not going smoothly. The two nurses (L&D nurses tend to be very good at what they do) were very calm, but were clearly getting very antsy. Finally, they started making very neutral comments asking the attending if he wanted an OB doctor to come in, and at one point telling him straight out that he needed to make a decision (over whether to do a C-section). One of the nurses quietly stepped out and came back in, a minute later the attending told her to call the OB doctor and she told him that she already had. Naturally, at this point the baby decided it wanted out and three minutes later it was delivered. When I left the room the other medical student on call told me that all the nurses in the workroom had been freaking out.

At ten a woman came into the ER with left lower quadrant pain, an ultrasound showed that she had a dermoid cyst (aka teratoma, a benign tumor that contains many types of tissue, sometimes even teeth and hair) on her left ovary with possible torsion. She went to the OR, we found a massive tumor (and torsion) and removed her ovary. I got the honors of cutting it open, it was quite possible the most disgusting thing I’ve seen in medical school. There were no teeth, but there was a lot of sickly yellow goo.

Right afterwards, another lady came into the ER with vaginal bleeding. She was diagnosed with a miscarriage. When we were done seeing her, I went back to L&D just in time to make it to a delivery. It was one of the resident clinic patients, usually the student gets to catch the baby—something I’ve not yet done. When we got there the intern took over and I didn’t touch it. She spent the rest of the night apologizing for stealing the delivery.

After that, I slept from 1:15 to 4:45, and was home by 8:00. Unfortunately I will be on call again on Saturday, which is by far the worst day to be on call.

OB: The ongoing saga

2007-02-03T10:50:00.000-08:00

OB is slowly growing on me, though I still would not consider it a career option. Last week I saw a couple more deliveries, though was not able to help much as they were somewhat complicated. One was going to be delivered by forceps but at the last minute things started going smoothly and the forceps were not necessary.

The patient population at this hospital is mostly inner city black, most of the mothers are younger than I am and either have no man in the picture or have an immature adolescent who laughs and makes jokes as the baby is being delivered. There have been a couple 24 year old G10P6046s (pregnant ten times, 4 miscarriages/abortions, 6 living children). It can be very discouraging at times. On Thursday I saw a married couple who were having their first child, and the husband stood and held his wife’s hand the whole time—it was a very nice change.

This rotation has brought up the subject of contraceptives. Obviously, anything that causes the death of an embryo I would consider wrong, but I have very mixed feelings about contraceptives that just stop ovulation. I have no problem with their being used by married couples, but at the beginning of the rotation I would have tended to not be comfortable with giving them to unmarried people because I felt like it would be facilitating a sinful and dangerous lifestyle. Now, I am not quite so sure—I am tending to think that they are going to live that lifestyle regardless of whether or not I give them contraceptives, but by giving them contraceptives I can at least stop them from conceiving a baby then having it aborted. I was talking about it to some of my Christian friends last night (one of who interestingly had no problem with contraceptives before, but now after being on Ob/Gyn does) and we came to the conclusion that if we were to give contraceptives out when we were doctors it would not be at all for the patient’s benefit because the only way the patient would be benefited would be to stop living a lifestyle of harmful and broken relationships. The only benefit is for society. Temporarily sterilizing these women prevents them from having babies for whom they do not have the resources (monetary and nurture-wise) to care for, and prevents the single mother/no family structure environment in which the children will inevitably be raised from being perpetuated. Having said that, isn’t the job of a doctor to care for the patient, not for society in general? And, I’m not sure that I will ever be able to comfortably sit down with an unmarried sixteen year old who has more sexual partners than she has fingers and discuss how she can continue this life but not get pregnant.

Mildly funny story: I had dinner at a hamburger joint with some classmates a couple weeks ago—our waiter who was very gay in the modern sense of the word but definitely not in the old gave us one bill, so the seven of us had to calculate out exactly how much each of us owed, write down the amounts with our names, then give him the list with five credit cards and a handful of cash—this is the conversation that ensued:

Gay waiter (annoyed at the prospect of 30 extra seconds of work): I need to know how much to charge each card.
Friend #1: We calculated the amounts and wrote down our names next to the amounts on this slip of paper. (and I'm deducting the time we spent on it from your tip)
GW (exasperated at the idiot medical student): That doesn’t help me, I need to know which card to use for each amount.
Friend #1 (wondering if he's serious): Our names are on the cards…
GW: Silence
Friend #2: grinding teeth shut and looking straight ahead to prevent herself from falling out of her chair laughing

Two weeks down...

2007-01-18T16:23:00.000-08:00

The belief that Ob/Gyn is the most time-intensive and busiest of the third year rotations is a myth. Friday I got to leave the hospital at 10:00 am, and (aside from the on-call day) have never left later than 4:00. Of the three hospitals students from my school rotate through for Ob/Gyn, this hospital is supposedly the busiest—another myth. The students at the two other hospitals seem to have much busier schedules than we do. Here, there is a lot of down time. After we round on our patients from about 5:45 to 6:30, except for the two students in L&D, we have nothing to do until clinic starts at nine or until there is a surgery (there isn’t always).

This week not much has happened. I’ve seen a couple OB patients in clinic, asked them all the same questions. I’ve been in two other surgeries, one removal of fibroids and one hysterectomy. I was in clinic for four hours one day, only saw two patients, and had to leave for the pelvic exam because the patient didn’t want a male in the room—I can completely understand this, and would probably feel the same were I a woman, but having said that it is a little frustrating since this is the one point in my career I will have to learn how to properly do a pelvic exam—if I don’t learn it here, that does not bode well for the women I will see as a physician who need pelvic exams (rare as they will be if I go into surgery). The thing I was mostly frustrated by was that this is a free clinic and patients have to agree to allow students and males to treat them in order to be accepted—they shouldn’t agree to be seen by males if they’re not going to actually allow it when they have been accepted to the clinic.

Today, I did actually get to help deliver a baby—I actually had my hands on the head and was pulling. That was a good experience. And it was nice to actually do something after literally sitting around doing nothing but study for ten hours straight.

First call night

2007-01-09T15:32:00.000-08:00

My first call night ever is over. This week I am on the gyn service, so the morning was spent in the OR—I saw two mesh repairs of prolapse causing stress incontinence. I couldn’t see a lot as I was standing outside the field of vision holding retractors for much of the time. It was interesting, but I think I am definitely more drawn to abdominal type surgeries. The doctor was very patient which was nice. The intern made a mistake in the procedure that wouldn’t have harmed the patient, but could have resulted in having to start the procedure all over again (though in the end that wasn’t necessary thankfully) and the doctor was totally calm about it as opposed to hitting the ceiling which unfortunately many surgeons would have done.

In the afternoon I went to clinic, where my presence was totally unncecessary as there were already many students there. I saw one patient who was spanish speaking. I was actually able to communicate fairly easily which surprised me as it’s been a long time since I studied spanish. After clinic I went to L&D with the other on-call student, and everyone else went home.

Nothing much happened at first, so I went to write post-op notes on the two patients whose surgeries I had seen, as well as one of the other student’s patients. The only issue was that one of the patients had low blood pressure and wasn’t making much urine. One odd thing about this hospital is it seems like the nurses think students are doctors—they would give me reports on my patients and ask me questions that they actually expected me to have an answer for. One even asked me if I was a resident even though I was clearly wearing a very short white coat—I guess it must be because this is not an academic hospital, but there are still loads of students here year round.

On L&D students are expected to write update notes on patients every 2-4 hours depending on how active the patient’s labor is. We also do history and physicals on all new patients coming in. Around eight I was sitting writing out an H&P when a resident when running by. As we were told to chase after any resident we see running, I followed—I got into the patient’s room (apparently she had just gotten up there two minutes before), and almost as soon as I walked in a baby just popped out. I didn’t realize deliveries could be that fast. Later in the evening, I went in to check up on a patient and the nurse in the room told me she was about to deliver, so I stayed and gowned up when the intern came in—this time I actually got to see the whole delivery. It looked like something from a science fiction movie. At first, one could just see a bit of hair, then a face slowly emerged—very bizarre looking.

Later, I did an H&P on a woman at 28 weeks who had an incompetent cervix—she had had five pregnancies before and all were miscarried. The baby was a breech presentation (feet first), so the doctor decided to do a C section. By far the bloodiest operation I have ever seen—it was crazy. The intern made the incision, opened the uterus, then suddenly the attending was pulling out this tiny little baby.

Around 1:00 I had a half hour before my next note so I layed down in the call room, got up to write more notes, then went back to sleep for forty minutes (the pain of having to get up almost makes it not worth the sleep), then got up to write more notes, but on my way I got a page saying one of my patients (who I thought was hours away from delivering) was giving birth. Again, the baby popped out almost as soon as I walked into the room—unfortunate, because this patient didn’t have a private doctor so I probably would have been allowed to do most of the delivery—oh well, I don’t think there’s going to be any shortage of deliveries in the next five weeks.

I went back to the call room at about four, but I do not have the skill (yet) of getting up and going to sleep multiple times a night—once I’m up, it’s really hard for me to go back to sleep—plus I was planning on going back to the floor at five, and I don’t trust myself to wake up, so I watched TV (slim pickings at four in the morning let me tell you) since I hadn’t brought a book to read aside from study materials (rookie mistake that I won’t repeat—studying after midnight=fifteen minutes per sentence). At five I went to round on my patients, though I just got vitals and wrote skeleton notes at first because I feel bad waking people up before 5:30. My two surgical patients were both already awake and doing well, so I took out the packing the surgeon had put in, and they should go home today. Then I went to see the C-section patient and one of the deliveries I had seen, both were doing well. The vaginal delivery should go home tomorrow, the C section in a couple days. Then at 7:30 I got to go home—I tried to get a cheeseburger on the way home since I was starving and craving meat, but the barbarians at the fast food restaurants only serve breakfast at that time, so I had to have egg rolls at home. Then I slept until about 3:30. Tomorrow I’ll go back at 5:30.

2007-01-06T15:38:00.000-08:00

Thursday was orientation to the hospital, it was by far the most overwhelming first day I have gone through in third year—fortunately, everyone else was just as overwhelmed. In the afternoon I saw two clinic patients for prenatal visits. I got to find the fetal heart tones with the doppler which was kind of neat. Friday two students had to go to clinic, and two to L&D. Since we all had lecture in the afternoon, the chief resident went over some things with us in the morning, then told those of us not in clinic and L&D we could leave to study. I know several students who can never believe residents really mean it when they say to go and will hang around for a while—I have never had this problem.

Next week I will be on gyn—on Monday there will be 14 surgeries to divide among students. Monday will also be my first official overnight call ever—should be interesting. I am more optimistic about this rotation than I was at the beginning of third year. It's still not really a career option for me, but I think it will be a good experience. Its procedural aspects are reminding me how much I liked surgery.

OB/GYN

2007-01-03T15:20:00.000-08:00

2007 already—amazing. My break was very nice, though it went by far too quickly. Yesterday we had our professionalism/patient centered care seminar (which did in fact last all…day…long…) which was pretty much as I (and 95% of the other students) expected it to be—the waste of a perfectly good day. At least I got to talk to some people I haven’t seen since third year began what with rotations being what they are.

Today I had orientation to OB/GYN which I shall be doing for the next six weeks. I’ll be at a private hospital with ten other students, and will switch between OB and GYN every week. Call will be every six days. One good thing is that the way the call schedule works out I will actually get four free weekends, and most are at the end of the rotation when I will be most tired. Full weekends just help so much—I could almost tolerate any schedule if I could just have two whole days off a week—one to get housework done/run errands and one to just completely relax. It is going to be a pain in the rear trying to figure out what we are supposed to do—as a group we are going to have to divvy up labor/delivery, clinic, surgeries, etc. It’s going to take a good week if not more to get things running smoothly, especially since many of us will only have a day and a half (we have lecture Friday afternoons) to work before the weekend.

I think I feel more clueless about OB/GYN than I have about any other rotation. Medicine and peds were both based at least in theory off of things we learned about the first two years, though surgery was less so. Pretty much all we learned about as far as OB/GYN goes the first two years was the hormones involved in cycles and pregnancy. It sounds like there will be no end of deliveries on this rotation though, so I should be pretty comfortable with them in a couple of weeks.

Half-way through

2006-12-21T11:14:00.000-08:00

I am now half-way done with third year! In less than a year and a half I will be a doctor. My last day of inpatient peds was yesterday and the shelf exam was today. It didn’t seem horrible, definitely not as bad as the medicine shelf, but it is one of those exams from which you leave having no clue whatsoever as to how you did.

This last week there has really been nothing worth posting. Lots of sick babies—I can at least now say that I feel very comfortable coming up with a plan for infants with bronchiolitis. My intern the ER resident did extremely well this month—our senior resident was very impressed with how quickly she caught on.

Now I get ten beautiful days off. The day after I come back we have a class “intersession” that will consist of eight hours of lectures and small groups about professionalism and “patient centered care”. Yippee. Woohoo. Save me a seat in the front row. They actually emailed us five articles on these topics that they expect us to read over Christmas. Yeah, that’s going to happen. I don’t fully understand why we have so much touchy-feely stuff in medical school—the vast majority of people I know in medical school tend (like I do—can you tell?) toward the cynical side—maybe it’s the more sensitive ones who go into the education side of medicine?

My next rotation will be OB/GYN—I’ll be at a community hospital that is known as the “baby factory”. It will be the first rotation I’ll have been on with overnight call. I’ve not particularly been looking forward to this rotation, but I suppose it will be good. It will definitely come in handy for the next time I get stuck on an elevator with a woman in active labor.

More peds

2006-12-10T13:51:00.000-08:00

This week has been fairly busy—nothing particularly exciting has occurred. I was on call Friday so had to go back in yesterday. I feel really bad for my intern—she had seven admissions and was basically running around all night long. Fortunately I was able to help her at least a little by talking to the radiologists, calling medical records, etc., but there is only so much one is able to do as a student—for some reason on this rotation interns have to write notes even on patients that students write notes on, as opposed to the typical “agree with above” addendum on most other rotations, so my seeing patients didn’t particularly help her any. Today is my last day off before Christmas break—I am becoming more and more glad that I did CT surgery, because now there is pretty much no schedule that I am intimidated by. Even though I have been working 60-70 hours a week this month, I am the most relaxed I have been in two and a half years. I think part of it is that since one doesn’t have to go to the OR, there is a lot more time to get floor work done thus one does not feel quite as pressed for time.

Wednesday we had a class meeting to talk a little about getting ready for fourth year, we’ll have another in February to actually schedule it. However, we have to pick an advisor in the beginning of January to help us make plans. One of the trauma surgeons spoke about things to do/not to do in fourth year for students interested in surgery. She recommended taking as few surgery rotations and as many medicine rotations as possible. Essentially she said the primary goal of surgery rotations should be to get letters of recommendation from the biggest names possible, while the primary goal of the medicine rotations should be to learn (likewise the medicine doctor who spoke said that students interested in medicine should do as few medicine and as many surgery rotations as possible), the idea being that surgery residents have their entire lives to learn about surgery, but not much time to learn about medicine. One of the things she was adamant about was that one should never do an away rotation at a place one is interested in doing a residency (again, the opposite of what the medicine doctor recommended). Apparently, only one visiting student to my school has been accepted to our program in the last seven years (my intern from CT surgery). I think that I am going to ask her to be my advisor—from what I hear she is super intense, but does take time to teach students. I think she would make things happen and would be able to help me figure out where to apply/what rotations to take that I could get good letters from. The only mildly scary thing is that picking an advisor, while not completely commiting one to going into a certain specialty, is certainly a big step in that direction. I’m pretty sure I want to do surgery, but I do like to have room to change my mind.

Bitter

2006-12-05T15:01:00.000-08:00

I had the weekend off—didn’t really do anything fun or productive, although I did manage to write up a couple H&Ps—we have to turn in four which wouldn’t be a problem except that we need to write up an extra discussion about the differential diagnosis. It’s not really hard, but it does suck up time.

Yesterday I was on call, it was busier than Friday which was nice—also, I got to leave at nine instead of ten since I had helped admit two patients by then. The first patient was a 13 month old boy with a five day history of forceful cough, posttussive emesis (throwing up due to coughing so hard), diarrhea, and low grade fever. His pediatrician had taken a chest xray, but they didn’t bring it—all we had was a sheet of paper from the radiologist that said “bilateral pneumonia”. We started him on IV fluids and an antibiotic (even though this is most likely viral). His lungs sounded good to me, but he got an albuterol treatment as well. Overnight though, he did start having lower oxygen saturations, so his pediatrician started him on steroids.

The other patient was a 5.5 month old girl with a two day history of diarrhea (16 watery stools/day), vomiting, and fever. She was admitted to the hospital because her bicarbonate was 11 (normal about 24) at her pediatrician’s office, signifying dehydration. Most likely viral gastroenteritis, probably rotavirus. She got IV fluids and an electrolyte recheck this morning which showed bicarbonate <5. So, we started replacing volume lost in stool in addition to maintenance fluids. I had to call the community hospital lab to get the results of her stool culture (she had gone to the ER on Saturday)—all that had been ordered though was a gram stain and culture—no viral tests were done, so of course all the results were negative.

I talked to my intern from the first couple days last night and it turns out the kid that we admitted to the other team (that she is actually on now) ended up having Kawasaki disease—we had initially been suspicious of it, but thought it unlikely after exam since the kid only met a couple of the criteria for it—lymphadenopathy and a rash, and since the rash started the day after taking amoxicillin we thought it was probably a side effect of the medication. Apparently though, over the last few days he developed the other classic signs: fever >5 days, bilateral conjunctivitis, and palmar desquamation. I kind of wish he had been admitted to my team as that would have been very interesting to see.

I got my surgery grades today—I did fine, but I am fuming right now. My first month of surgery I was on a team with two other students, an intern, two senior residents, and four attendings. I ended up getting evaluations from (drumroll) the intern and one of the attendings (the one I had virtually no contact with). The evaluation forms essentially give several categories in which the evaluator ranks the student 1-9, and then there is a space for comments. The attending gave me all sevens and wrote no comments, and he did the exact same thing for the other two students. Given the fact that neither of the two attendings I had more contact with bothered to fill out an eval, I’ve got to give the one attending credit for filling one out, cursory, mechanical, and essentially meaningless as it may have been. What really ticks me off is that neither of the senior residents, the two people who were in the best position to accurately rate my performance, filled one out either. The other two students weren’t evaluated by them either, so it’s not just me. Incredibly frustrating—I’m supposed to pick an advisor out of the faculty over the next month—I have medicine doctors I can go to, but since none of the surgeons I have worked with are apparently even aware that students exist I’m not quite sure how that’s going to work out. Guess who I won’t be requesting letters of recommendation from? /end of bitter mini-rant—at least no evals are better than bad evals.

This afternoon we had to go to an hour-long ethics discussion—quite possibly the most worthless hour of the week, and that’s counting the hour I spent on the weekend going back and forth between the basement and my room to see if my clothes were dry because I really wanted to go to bed but had to have clothes for the next morning. I can’t really explain what was discussed because really nothing was. Fortunately we only have one more session and we’ll be discussing an actual case so I might be able to at least feign interest. On the plus side, our interns told us we didn’t have to go back to the floor, so we got to go home at 2:30.

Inpatient Peds

2006-12-02T10:09:00.000-08:00

I can’t believe it’s already December. I started pediatric inpatient on Tuesday—usually we would switch rotations at the first of the month, but with Christmas things got shaken up a bit. On peds each student is paired up with an intern, but the interns all switched on the first. The intern I had the first couple days is going to go into dermatology, but she is doing a pediatric internship. She was very nice and extremely smart and competent and it turns out we went to the same undergrad in California. The intern I just got yesterday is also very nice, but she is an ER resident who hasn’t done inpatient pediatrics since her third year of medical school (ER residents rotate through a bunch of different specialties in their intern year). One of the first things she told me was that she hates kids. I likely won’t learn as much (at least about pediatrics) from her, but the good thing is that I know I’m going to get a great evaluation from her—after we spent two hours going over a chart to transfer a patient to our floor she told me that anyone who has to deal with that [garbage] deserves a good eval. Since yesterday was her first day, she had no idea about how rounds/presentations work; one of the other students on the team told me it was the first time he felt like we knew more about what was going on than the intern did. I think she’ll be fine in a couple days, though she has not been shy about making it clear she really doesn’t care what any of the supervising residents think about her since she has no intention of having anything to do with kids after this month.

One of the first patients I saw on this floor was a 5 month old girl with mild holoprosencephaly, a cleft lip/palate, seizures, and central diabetes insipidus. She had been there for two weeks and will hopefully go home on Monday. The main problem is the dosing of her ddAVP—too much and her sodium drops, too little and it shoots up.

I was on call Thursday, and helped admit two kids. One was a 2 year old with a 4 day history of fever who developed a rash the day after being started on an antibiotic. The other was a 19 month old with a two week history of vomiting and diarrhea who presented to the ER with severe dehydration and hypoglycemia. The two year old we admitted for another team, so I don’t know what happened with him; but the 19 month old (after getting a lot of IV fluids) was feeling better yesterday and probably went home this morning.

The way this rotation works is that we are on call every four days (intern stays overnight, students leave at ten, then the next day the intern has to leave by noon [though they usually don’t] and the student stays to take care of loose ends). Weekends we have off unless we are on call or post call. Essentially, that means that I have three days off this month, and two of them are this weekend. Next week I will be on call Friday, so will have to be there on Saturday, then the next week I will be on call Saturday so will have to be there Sunday. Even given this, I still prefer inpatient to outpatient. I wouldn’t mind having an outpatient month once every six months or so though.

Days off

2006-11-25T13:25:00.000-08:00

Nothing particularly exciting happened at my various pediatric clinics this week (though I did find an ear infection in a kid who came in for something totally different!). This rotation has been like a vacation—less than forty hours a week of being in clinic/lecture, weekends off, and a four day weekend for Thanksgiving—but I am ready for it to be over. I am discovering that there is such a thing as too much free time. I’ve tried to use a lot of the time to study, but since there is no stress this month I have very little motivation to study pediatrics—I have started going through some step 2 questions though. Tuesday I’ll start pediatric inpatient which should be quite a bit busier. I am missing the OR a bit.

Since I spent yesterday lying around doing nothing productive I decided to go to the Saturday Free Clinic this morning. It is much better as a third year than as a second. Usually it works by the M1 getting the patient and measuring vitals, then the M2 interviewing the patient, then the M3/M4 going and filling in any gaps and doing the physical, and coming up with a plan. Then the attending looks over everything, sees the patient, and signs the notes. Today, however, there were a lot of M3s, so I saw two patients by myself. The first patient, though, was reported to me by an M1 and M2. It was a young lady who wanted an annual pap smear and STD check, so there wasn’t much history to get. I basically just listened to her heart and lungs, then deferred the rest to an M3 who just finished OB/GYN. There weren’t any other M1/M2 teams in need of an M3 so I went ahead and got my own patient, a 35 year old man with type 2 diabetes and hypertension. He weighed 332 lbs, but had lost 40 pounds over the last two months with diet and exercise. I congratulated him and told him to keep it up. His blood pressure was still high though, so I told him we’d probably increase the dose. His hemoglobin A1c, a measure of long-term blood sugar control, was 9.2 (high). I reported to the attending, and he agreed with me as to increasing the blood pressure meds. He didn’t want to start diabetes meds though, since the patient was doing so well at losing weight.

The next patient was a man with rectal pain off and on for several years (he was diagnosed with hemorrhoids 7 years ago) worsening over the last two months. He described large, visible masses, but when we looked the attending could not detect any hemorrhoids. The man had been trying a lot of ointments and hot baths without success. From the patient’s description I thought he would need surgery—our exam was not really consistent with that, but we went ahead and referred him to a general surgeon for a second opinion anyway. Since this is a free clinic, the doctor who oversees it will have to approve the request.

This was the first time I have had any significant contact with the M1 class—I could not believe how young some of them looked. What’s scary is that I’m the same age most of them are—if I look that young I can definitely understand some of the comments I have gotten from patients!

Highlights of the Last Week

2006-11-15T15:41:00.000-08:00

1) I went to the Global Health Missions Conference which was excellent. Very amazing and inspiring to hear of people who give up comfortable and lucrative lives to serve God in third world countries. Steve Saint was one of the speakers--I had never realized that he toured with one of the men (now a Christian) who murdered his father.

2) In my absence one of the local radio stations began playing nothing but Christmas music--you'd think they could at least wait until after Thanksgiving.

3) I was told by a four year old that I looked too young to be a doctor--I've often heard this from people two to three times my age, but from someone 1/5-1/6th? Give me a break kid.

4) I realized that I am terrified of little kids with fevers--I do my utmost to avoid touching them and acquiring any of their germs.

Short

2006-11-07T19:18:00.000-08:00

I had endocrine clinic all day today. I was with the attending and a fellow in the morning, and towards the end the attending let me see patients by myself—always better than merely shadowing. In the afternoon I just shadowed the nurse practitioner. One of the patients was a seven year old girl whose parents were concerned that she was beginning puberty. The father was an OB/GYN who turned out to be one of the doctors who had seen the fellow when she was pregnant with twins—she mentioned to me after the family left that it was stressful enough treating other physicians and their families let alone a physician she had gone to. The father was concerned about an adrenal or ovarian tumor, but the endocrinologist reassured them that those problems would cause different symptoms and the girl’s condition is most likely benign.

In the afternoon we saw a 14 year old boy with Crohn disease who has been 4’7” for the last three years. He looked like he was 11 or 12, but the father seemed to be a lot more concerned than he did. The NP saw him first and spoke to the parents about possible treatments, then the attending came to see him. He had normal growth hormone levels, but the bone age of an 11 year old—this is actually a good sign because it means that he will likely eventually gain back some of the inches he missed the last three years. The doctor recommended that he get testosterone injections for three months followed by monitoring for another three.

Community peds

2006-11-06T17:56:00.000-08:00

Today I did not have to go to clinic until 2:00pm:). I could get used to this. I went to a community pediatrician's office today. It was fast paced, so I didn't get bored (plus, I was only there for 2.75 hours!). We saw several patients, ranging from asthmatics to regular check-ups. Fortunately the children were all well-behaved, I didn't get spit on like one of my friends did last week.

I have a feeling that the pediatrician might be a homeschool dad--the pictures of his family in his office show that he has six young children, but I didn't get a chance to ask. He greatly raised my opinion of him when he encouraged the patients' parents to vote "yes" tomorrow on the gay marriage ban (in a non-confrontational way)--the liberal doctors at school would have thrown a fit to hear that--it was great.

Tomorrow I have to go to endocrine clinic all day, which seems an incredible hardship after the last week's schedule. I am going to be so spoiled by the end of this rotation, reality is going to strike hard next month.

Altruism

2006-11-03T14:36:00.000-08:00

Today was rather painful, but I can’t complain about getting out at 3:00. We had to go to pediatrics grand rounds at 8:30—a child psychiatrist who was triple board certified in peds, peds psych, and something else (psych?) from New Orleans spoke on various issues, I think mainly child abuse and the foster care system, but to be perfectly honest I was fading in and out the whole time. Unfortunately the auditorium was stadium seating so I didn’t feel comfortable playing Bejeweled on my PDA. It is really funny to see how people with different personalities react to different things—a student who also wants to be a surgeon verbalized my sentiments by telling me this rotation is killing her and that being a child psychiatrist is her worst nightmare, the student I was on CT with went up and spoke to the psych guy after because she thinks being a pediatrician+child psychiatrist would be the most fun job on the planet.

After grand rounds we returned to the nursery to present H&Ps. However, first we had to give a 5 minute talk on the process of fatty acid catabolism and how one would diagnose long chain acyl dehydrogenase deficiency in a child since yesterday none of us could remember how fatty acids were metabolized in cells. It went well, and fortunately only one of us (not me!!!) had to present an H&P. We were done by 11:00, so had two and a half hours off before going to our hour and a half lecture on (drumroll) altruism. The lecture ended up being (surprise, surprise) somewhat pointless. The problem is that they always pick the nicest, most likeable people to give these pointless talks, so one feels really bad complaining about it. Very sneaky.

I got spoiled for the last three months by leaving the house before most people are up. These last two days I have left right in the peak of traffic, so what used to be a blissful cruise straight down the highway for 30 minutes is now a frustrating 45-50 minute start-stop session that is making me want to tear my hair out.

Peds

2006-11-02T19:40:00.000-08:00

CT surgery is now over—I have bittersweet feelings about that. Monday I saw a minimally invasive repair of an atrial septal defect. It was quite amazing, the surgeon did the entire surgery through a 2-2.5 inch incision in the inframammary fold. Much superior to having a footlong scar down one’s chest, especially when the patient is a 21 year old woman.

Tuesday was the surgical exam, which was nowhere near as hard as the medicine exam, but I think I could have done better had I had more time to study. Wednesday was pediatrics orientation which was the typical orientation spiel. The girl who was on CT surgery with me has the exact opposite taste as me—she hated surgery, and almost started crying with joy at peds orientation when she heard about the clinics we would be going to, I really liked surgery and don’t care for clinics.

Today I went and basically just shadowed two nurse practitioners at an endocrine clinic. The first patient was an 11 year old girl who was very overweight and has high cholesterol. She’ll be getting a number of tests to check for various metabolic disorders and will continue to see her nutritionist. The second patient was 17 year old girl with a hormonal disorder due to unknown causes. The last patient was a one year old girl who is getting growth hormone. The patients were interesting, but altogether it was rather boring. I do not think I am cut out to see patients in the office all day long.

This afternoon I went to the nursery and had to do an H&P on a newborn. I had to get the details for the history entirely from the chart, so I had to spend what seemed like hours going over it, and tonight I have to write it all out and be ready to present it tomorrow.

I can’t say that I’m not going to appreciate the weekends off this month (and four—day—weekend on Thanksgiving!!!), but I think I can safely say pediatrics is not for me. In all fairness I think I would probably enjoy clinic as an attending, having my own patients instead of just observing other people’s. Also, this is the first day of the rotation and I usually hate the first week of any rotation.

CT stuff, cont.

2006-10-29T13:53:00.000-08:00

I just shattered the 80 hour work week—actual number now is 90. Yesterday I had to round/call consults/pull chest tubes from 6:00 to noon, then came home thinking I would have the afternoon off, go to bed early, and have all day Sunday to relax and do housework. Ha. I went back in at 3:00 for an emergent bypass—the fellow had to work on harvesting the saphenous vein from the leg, so I actually got to first assist the surgeon for a while—much more fun than just watching. When the fellow was done, I got to close a lot of the skin and bandage the leg. The bypass went by very quickly (4-5 hours) for a bypass, and I was excited to still get home and be able to get enough sleep that I could go to church in the morning. Naturally, it was about that moment that the cath lab called and said that yet another man with crushing chest pain was just discovered to have 90% occlusion of his LAD coronary artery. To make a long story short, I left the hospital at 1:30am. It actually was very interesting though as this latter surgery was done off bypass with the heart beating—up til then I had only seen bypasses with the heart stopped. It makes for a much faster surgery. One thing that I have learned on this rotation that I was clueless about before is the closing times of the fast food restaurants where I live. Would you believe Burger King is the only one open til 2:00?

All in all, this has been a pretty good month. The surgeries I have seen are by far the most exciting and interesting surgeries I have ever seen (in my admittedly very limited experience). It is amazing to just see a beating human heart, let alone touch it and work on it. The surgeries are literally life saving, adding on years to someone’s life expectancy with just hours of labor. However, the lifestyle is horrible—I thought my general surgery month took a lot of time, compared to this it’s nothing. Once I got used to it, being at the hospital 70-90 hours a week is surprisingly doable, but you have to be able to give up every other commitment in your life. I can’t imagine being married, much less having kids on this rotation. It was not a surprise for me to find out that CT surgeons have a 90% divorce rate, a statistic well reflected by the CT surgeons at my school. Several of them are already on their third wife and their kids completely resent them. So, while I am very glad to have had this experience, I think I can safely say that CT surgery is not going to be an option for me.

CT stuff

2006-10-28T12:51:00.000-07:00

I have just officially worked my first 80 hour work week. Monday is usually the day when we have nothing to do aside from working in the hospital—no lectures, teaching rounds, etc., so I went ahead and just wore scrubs instead of professional dress. Big mistake. At about 6:30 I overheard another student telling her resident that we had OSCEs (interviewing fake patients) that morning. I and the other student on CT surgery had totally forgotten about it. I ended up having to drive all the way home (30 minutes in good traffic) to change and all the way back, getting to the test site with about five minutes to spare. A very annoying way to start the morning. Tuesday I saw a triple bypass in a 45 year old man. That evening the clerkship director had dinner at his house for all the students on surgery. His wife is a “3/4 time” family practice physician and they have four very energetic children all under the age of nine. The oldest child was having fun talking to all the medical students about electrons and hormones.

Wednesday was lecture. Like last week, I was hoping to leave after lecture and go to the library and study and finish writing up H&Ps. Also like last week, these hopes were dashed. I ended up having to go into the tail end of a (you guessed it!) bypass. I left at about 8:00, so I did manage to make it to Bible study. Then I had to stay up til midnight finishing the H&Ps.

Thursday was my day to go over to Children’s hospital to watch a pediatric surgery. It was a several month old child with pentalogy of cantrell, a very rare congenital disorder. The child essentially had an opening between the two main chambers of her heart which needed to be closed. It was really quite amazing—her heart was about the size of a golf ball. The surgeon sewed in a patch to fix the defect. Unfortunately, when he tried to take her off bypass, her heart didn’t want to start again. They got an echo and found that the middle part of the patch was buckling and blocking her aorta. The surgeon opened the heart again, finnagled with it, then tried to take her off bypass. Again, no success. He ended up having to take the patch out. They put her on ECMO, a form of cardiopulmonary bypass, and are going to let her rest for a couple of days before trying anything else. I left the case at 1:30 am, thus setting a new record for the longest surgery I have ever been in: 16 hours. Unfortunately I was wearing contacts so I had to drive home to take them out, sleep two hours, then go back. Had I known I would be there so late I could have just worn glasses and slept at the hospital which would have been a lot easier. At about 9:00pm I decided that I am just not meant to be able to study for the exam on Tuesday.

Friday morning I saw a consult, a woman with a newly found lung mass, had the cup of coffee I had been dreaming about since Thursday morning, and saw an esophagectomy. The surgeon removed the esophagus (the patient had Barrett esophagus which strongly predisposed her to esophageal cancer), then formed a tube out of the stomach and brought it up through her chest and attached it to the remaining cranial portion of her esophagus….I just got paged—I have to go back in for an emergent heart procedure—I guess I’m really not meant to study for the exam on Tuesday—to be continued, likely with an explanation of why I will never be a cardiac surgeon...

Rounds

2006-10-22T13:30:00.000-07:00

It hit me. I went to bed at ten, when I woke up I thought it was probably about nine—actually it was 1:30pm. That pretty much destroyed any chance I had of doing something productive. I did manage to type up a couple of H&Ps, eat dinner, then go to bed at ten. Naturally, since I had just gotten 15 hours of sleep I stayed awake for several hours, which would have been fine if I didn’t have to wake up this morning at 4:45. I do feel better now with 16oz of coffee in me.

This morning I saw 6 patients in just a little over an hour. Since the intern has been avoiding the obnoxious patient I have previously described she made sure he was one of the ones I had to see. Surprisingly I managed to keep my time talking to him at less than three minutes, and was starting to be less inclined to dislike him. That changed when we rounded with the attending and fellow and he went into gory detail about how his wife has a phobia of touching him, refused to wash his back this morning after washing his hair, and then described the most private matters of his personal life that I really did not need or desire to hear. Somehow he worked into the conversation that he wears $1500 suits when he goes out so he can attract women’s attention, that his wife doesn’t understand that, and that he dresses better, is taller, and is more handsome than any of us (the attending, the fellow, and me). I think he has some narcissistic tendencies. After we left his room, even the attending (who enjoys telling crass/dirty jokes in the OR) said he felt like taking a shower. We were going to discharge him, but his blood cultures grew bacteria so now we have to monitor him for several days.

Transplant

2006-10-20T16:49:00.000-07:00

This week has been rather busy. I can’t really recall off hand what went on Monday and Tuesday, but Wednesday was lecture from 6:30-6:30. I had to present the tracheal stenosis patient to my classmates—typically one presents the patient’s chief complaint and students have to ask questions about the history and try to come up with a differential diagnosis. Three other students went before me, and each one took more than a half hour to present, which made me a bit nervous because I didn’t think I could stretch my presentation out past 15 minutes. Thankfully by the time it was my turn we only had about twenty five minutes of class left so the doctor heading the discussion told me just to breeze through, so all went well. I decided to skip the last lecture since 11 hours was quite enough for me, and went back to the workroom thinking that I would check in and be told to go home, then I could go to school, stop by the meet the surgeons cocktail party that was going on (I probably would have just ended up standing by the hors'douvres table cramming food down my mouth avoiding social contact anyway), then go to the library, study (which I haven’t had time for yet this week), change, and go to Bible study (this night each of us was going to share favorite passages—my choices were Job 19:23-27 and Rom 8:18-39). Unfortunately, when I got back I was told that a heart bypass which had started in the morning was still going so I had to scrub in. It ended up being the CABG that would not die. The patient, showing flagrant disregard for my plans, refused to stop bleeding (apparently he had an anti-phospholipid syndrome that messed with his clotting factors). As the hours ticked by, my plans became increasingly shorter. I managed to hang on to the hope that I would at least make it to the tail end of Bible study, but that hope, like so many, at last died a horrible death. The CABG went on til about 11:00pm, the doctor had been pretty calm the whole time, but afterwards he told me he thought that the patient was going to die on the table. I wrote the op note and went home for the three and a half precious hours of sleep I would get before coming back to the hospital.

Yesterday I went in, saw several patients, then scrubbed in to two cases. The first was a lung tumor removal, the second was a left lung removal. The fellow had to go to clinic, so I first assisted the surgeon (ie I held retractors). I got a very good view though, it was quite interesting. And between cases, I managed to go to the free drug rep lunch hidden back in the general surgery offices. After the lung removal came the exciting part. A heart in Colorado had just become available for transplant, and was a match to a man in the city in which I live. One of the surgeons had flown out early in the afternoon, and was on his way back with it. I was not on call so I could have gone home, but since this was possibly a once-in-a-lifetime opportunity I stayed. It was definitely worth staying for. Two surgeons worked together to get the patient ready—they opened him up while the donor heart was still in the air so that he would be ready for transplant as soon as the heart arrived. At 8:30 a group of people walked into the OR wheeling an ice chest. The surgeons put the patient on heart lung bypass (a machine that keeps blood circulating through the body when the heart and lungs are not functioning), cut out the patient’s heart, and tossed it, still beating, into a bowl. It was huge from chronic heart failure. The donor heart was much smaller. They prepared it, and sewed it in over about an hour’s time. Then, they monitored it, and finally closed at 2:00am. The other student and I left at about 2:30. Since we had to be back at 6:00, I considered not even going to bed because I was afraid if I did I would not be able to get up. I was too tired though, so I decided to take an hour nap before showering and going back. Although I have no memory of this, I somehow ended up getting out of bed, turning my cell phone alarm off, and getting back into bed, because when I woke up (I even left my bedside light on so I wouldn’t fall too deeply asleep) it was 6:15. Since I live a half hour away from the hospital, I had to page my intern and tell her I would be late, fortunately she was all right with it.

I finally got to the hospital at 7:00, and just had to see one really repulsive and manipulative patient. Naturally he was the type who likes to hear himself talk, and since I am too nice to be rude (I need to work on that) I had to sit (by his order) and listen for a good long while to his theory about constipation, his self-remedy, and what we as compassionate hospital staff should do about it—no more details needed. He was really freakish, he would make horribly suggestive comments to every female who walked by (he’s 62 by the way); if I were one of them I would have walked in and knocked him out. Plus he referred to himself in the third person. But, he does have serious physical problems and still needs good care regardless of his personality.

I was hoping that we would be allowed to leave early, but this was not to be. We had to round and do floor work until 4:00. Now I need to go to bed since I have had 6 hours of sleep in the last 60 hours (I am still surprisingly energetic, I am sure it is all going to hit me soon…)

More CTS

2006-10-14T08:39:00.000-07:00

73 hours at the hospital this week. Last night I thought that I would probably break 80, but fortunately that was not necessary. This week I have seen several bypasses and an aortic valve replacement as far as heart surgeries go. The aortic valve replacement surgery was a little dicey, when the surgeons tried to take the patient off of the heart/lung bypass machine (keeps the blood circulating while the heart is stopped) his right ventricle did not function properly; the only reason they could come up with was that they might have accidentally messed up the right coronary artery. They did a bypass on that, and since they were so busy I got to sew up the patient’s leg (they had removed his saphenous vein for the graft). It took a while, but it didn’t look too bad when I was done. Finally we took the patient to the ICU, where he proceeded to code. The surgeon at first thought he wouldn’t last the night, but he eventually stabilized and was doing better the next morning.

As far as thoracic cases go, I watched a joint otolaryngology/cardiothoracic surgery on a man with a narrowed portion of his trachea. They had to open up the neck, and basically cut out a portion of the trachea then sew the two ends together. At the end they took the most massive suture needles I have ever seen, and sewed his chin to his chest to make sure that the patient wouldn’t move his neck the wrong way and kill himself. The sutures have to stay in for a week, seeing them made me want to hold my chin really close to my chest for the rest of the day. Yesterday the other student went into a bypass, and I saw two very quick procedures, a sympathectomy and an esophageal dilatation. The sympathectomy was the removal of a couple ganglia in the sympathetic chain to treat a woman’s hyperhidrosis—essentially she has had really sweaty hands, armpits, and feet since she was a child, and it has been embarrassing as well as a nuisance particularly when she has to handle paper at her job. As soon as the surgery was over she was cured. When I saw her this morning she was talking about what a miracle it was.

The rest of yesterday was very relaxed. One of the patients I saw in the morning wanted to set me up with her grand-daughter (not surprising, I'm quite a catch:) who is apparently a first year at another medical school. I rounded on patients with the attending, pulled a chest tube, and (!) ate lunch for the first time in a week. That, however, was a trade-off for not getting dinner. At about five, when I was getting geared up to leave, a man came into the ER with a ruptured esophagus. He went to the OR at about six, and I stayed to watch. When esophaguses (esophagi?) rupture, one tries to repair them in the first 12-24 hours. However, this man had had symptoms for more than a week, and was thus very infected. The ER put a chest tube in, and (I did not go down) you could smell him throughout the entire ER. In the OR, they opened his chest, and his left lung and chest wall were completely covered in white gunk. The surgeons spent two hours peeling it off. The esophagus was a mess, and was impossible to repair, particularly with the infection, so they stapled his stomach closed, opened his neck, pulled out his esophagus through the hole (the distal end was very nasty looking), cut it, and sewed the remaining end to his skin to form a “spit fistula” through which his saliva can drain into a bag. They then put a tube into his small intestine to feed him. He will have to remain like this for the next 6 months which will allow him to heal up. Then, they will re-open him, make a tube out of a portion of the stomach, and attach it to what is left of the esophagus which will allow him to eat. The reason for his rupture is because he is an alcoholic, now anything he takes by mouth will immediately drain into his ostomy bag. I wonder if he will stop drinking, or if he will put the alcohol directly into his intestine tube? The surgery finally ended at 11:30, and I got to come home and sleep for 3.5 hours before going back this morning. I wrote notes on four patients, then my intern told me to go home which I gladly obeyed. There is bypass scheduled today, and I was very afraid that I would have to scrub in on it which would have meant I would be there til 5 or 6 pm. I’m happy with 8am:). Now I can write up a couple H&Ps that are due, put together the presentation I have to give on Wednesday (I’m presenting the tracheal stenosis patient because he has some very nice CT images), and actually study for the exam that almost half my grade will be based on. Sad story of the week: I set my VCR to tape Lost this week, but when I got home it never started recording:(. Now I’m going to have to try watching it on the ABC webpage and put up with the constant freezing and re-starting of the images.

CTS

2006-10-07T10:11:00.000-07:00

This week has been my first week of cardiothoracic surgery. It is quite a bit more laid back than I was expecting it to be. The team is set up a bit differently than what I am used to. The only resident is an intern. There are five attendings, two or three fellows, and then several nurse practitioners and PAs. The NPs and PAs manage the basic components of patient care in the hospital, except on the weekend when the intern takes over.

Monday was orientation; afterwards the other student and I saw the last half of a lung lobectomy (removal of a lobe of the lung) for lung cancer. Tuesday we had teaching rounds in the morning which made us miss the one surgery scheduled. In the afternoon, we saw a consult patient. We went to her room and looked through her chart, then as we were about to knock on the door it suddenly opened and the patient, all dressed up in coat and gloves was about to walk out. She informed us that she was going to go to the grocery store. We talked her into letting us talk to her first—she was a very pleasant lady, but didn’t tell us anything relevant as to why she was in the hospital. We finally left, and I mentioned to the front desk clerk that she was about to go to the grocery store. They got the nurse and put a guard at the door.

Wednesday was lecture all day. Thursday the other student scrubbed in for a triple bypass with aortic and mitral valve replacements, and I went to clinic. Clinic was very painful, although I did learn a lot and saw a wide variety of problems. The pain was largely because for the most part I just shadowed the doctor and nurse practitioner, and also because there was no lunch break so I didn’t eat from 5:30am til 5:00pm. Thursday morning I experienced what was quite possibly the most awkward situation of my medical career. I went to round on a young lady I had not seen before (on this service students often round on different patients every day which means that in fifteen minutes we have to read the chart and figure out why the patient is there, go see the patient, and then write a note including a plan). She had had cancer as a child, then was found to have some suspicious lesions on a chest x-ray recently, so she had to have the lumps removed. I’m pretty sure they were negative for cancer. I went into the room and introduced myself, then she asked if I knew a certain person who happens to be another third year student in my class. I said yes, and she told me that he is her husband. Then, all of the sudden, he walked into the room to see her. It was horribly uncomfortable, what on earth do you say to someone you don’t know very well whose wife just came close to being diagnosed with a fatal disease in her early twenties and you didn’t even realize he was married, much less in this situation? What makes it worse is that I can’t even share this story with my friends at school because it involves someone we are all familiar with.

Friday the four students and I went to an hour and a half long pimping (doctors asking students questions for the purpose of teaching, a practice often abused in the past by some to humiliate students) session at the VA with a cardiothoracic surgeon which was rather painful but very helpful. I found it impressive that he was taking an hour and a half out of his day to help third year students. And he brought cookies, which ended up being my last caloric intake until 8:00pm. When we got back to the main hospital, I went to a CABG x2 (double bypass). It was about a five hour long surgery but very interesting. Very amazing to be looking at a beating human heart. My role was basically as an observer until the end when I helped the fellow wire the sternum back together and sew up the incision. After, we rounded on the patients, then the intern and I went to see how the operation the other student was involved in, an esophagus removal on a 420 lb man, was going. The intern really wanted to go home, so she was hoping to make an appearance then leave, but the attending said as soon as she walked in that she could scrub if she would like, so of course she couldn’t tell him that she wanted to go home. The other student, who has no interest in surgery whatsoever, looked like she was ready to die. The case ended in an hour, and I was at last able to go home and watch the new episode of “Lost” which I had taped two days before. It is getting very interesting.

Done with General Surgery

2006-09-30T10:52:00.000-07:00

Yesterday was my last day of general surgery. The whole month is a blur. I had to go in to round on Saturday and Sunday, fortunately for only about three hours each day. Monday was clinic. Tuesday I got to first assist on two laparoscopic gastric bypasses (the intern was in class for the week, so I was the only other person aside from the surgeon to scrub in) which was pretty neat. I held the camera while the ports were being placed (then the robot took over) and held intestines back with a laparascopic grabby-thingy. A trained monkey could have done equally as well, but at least I was actually a necessary part of the surgery. Wednesday was lecture for eleven hours, then evening rounds with the resident. That evening I was supposed to bring pizza to my Bible study at 7:00. I ordered it from the hospital at 6:15, clinging to the hope that I would leave by 6:40. When 6:35 came around with no signs of leaving, I had to call one of my friends and ask them to pick it up. I left at 7:20. Fortunately they saved me some pizza. Thursday I scrubbed into a breast tumor excision which was interesting—before removing the tumor the surgeon injects some dye and a radioactive substance into the breast, and within a few minutes both substances are brought into the lymph node closest the tumor. They use some type of radiation detector to find the node, then remove it to look for tumor spreading. This particular surgeon tends to drive the residents nuts because of his micromanaging, but he is good at pointing things out to students which is nice, particularly since I am going to have to try to do a month with him early in my fourth year to get a letter of recommendation for residency. That evening, the bariatric surgeon took the students and residents out to dinner at a fancy restaurant—I got veal with prosciutto and eggplant which was excellent. Very nice of the surgeon. Friday I saw a laparoscopic hernia repair and an ileostomy reversal. The surgeon for the latter also has some micromanaging tendencies apparently, and my senior resident started showing her frustration by the end of the case. I imagine that after eight years of school and three years of surgical residency it must be annoying to be ordered around about every little thing. My duties consisted of standing in a really tight corner and holding retractors at awkward angles for long periods of time. I left the hospital at 6:30, thus finishing my 120 hours of work in 12 straight days marathon. Monday I start cardiothoracic surgery.

Rounding

2006-09-23T09:57:00.000-07:00

The last couple days have been rather uneventful what with almost all our attendings being on vacation or at conferences. Wednesday was lecture, Thursday had no operations or clinic. We finished rounding at 9:00, then proceeded to stay and study at the hospital until after 3:00. We should have been allowed to go home at nine; I decided at the beginning of this rotation not to let anything phase me so I was OK, but the two other students were steaming by the time we were finally sent home. Friday we had a couple of cases in the morning, I scrubbed into a hemorrhoidectomy—I hope I never have to have that operation. There again was no clinic, so the residents took us out to lunch at a Mexican restaurant. Very nice of them. I had to go in this morning to round on patients with the resident, and have to go in again tomorrow—payback for having the last two weekends off. Fortunately we round later and leave by ten or eleven on the weekends, so it is not too bad, but unfortunately I have to miss church.

Scalpel

2006-09-19T17:52:00.000-07:00

This morning I saw a reversal of an ileostomy. The patient apparently had had rectal cancer previously and had undergone surgery to treat it. The surgeon created an ileostomy (small bowel empties into a bag stuck to patient’s skin) to let the colon heal. Now that it has healed, the ileostomy could be repaired. I got to sew the incision at the end.

The afternoon was spent entirely in clinic with one other student. One patient was a 97 year old lady who had a sebaceous cyst on her chest that had grown to the size of a small apple since July. The doctor decided to do an incision and drainage to get all of the pus and nasty stuff out. He handed me the scalpel, so I got to make an incision on a live person for the first time in my life. Very neat.

One of my other patients has had intermittent burning epigastric pain for the past several years. A CT scan she had last month showed some gallstones, so she assumed the pain was due to that and made an appointment with the surgeon (for some reason she doesn’t have a primary care doctor). Turns out she has had acid reflux and probably could have easily corrected it by seeing a family doctor years ago.

We have lecture all day tomorrow. It can be annoying sometimes, but it can be a nice break too.

Gastrojejunostomy

2006-09-15T18:16:00.000-07:00

This week has been busy, I calculated that I worked 62.5 hours in five days although that really doesn’t sound like that much compared to how long I feel like I have been working. I saw four surgeries including two biopsies (I didn’t do anything except watch), a laparoscopic Roux-en-Y gastric bypass (I just watched), and a subtotal gastrectomy with revision of the gastrojejunostomy. The lap bypass was very interesting, it was amazing to see the surgeon do everything including suturing with long instruments through tiny holes in the abdominal wall. What was discouraging was that one of the surgeons (did a laparoscopic fellowship after surgery residency and has been in practice for several years) kept getting yelled at by the head surgeon for making mistakes—I always thought that once one got out of surgery one didn’t need supervision anymore. This could be a longer road than I thought…

The gastrectomy was interesting though I couldn’t see a lot of it since the surgeon was blocking my view. The patient had a gastric bypass a couple years ago, and a fistula (connection) had developed between her stomach pouch and the rest of her stomach, essentially making her bypass useless. The surgeon opened her up, and spent several hours with the resident dissecting to the proper area. They ended up just taking out the main stomach since it had lost much of its blood supply. The resident let me staple the incision, and I grabbed some ties on the way out to practice my knot tying (I learned the one-handed tie a couple of days ago) at home.

This morning was GI conference, and I was supposed to present a patient who had left the hospital the second day of this rotation, I had never spoken to him. Yesterday I had to track down his chart via the very crabby nurse practitioner, and when I did get it it really didn’t have much information. I spent 1-2 hours piecing together his history, and fitting it into a one minute spiel. I got home last night and had to practice it in the small amount of time I had before going to bed. At the conference this morning, the attendings spent so much time talking about other patients that I thought they wouldn’t get to me. Fortunately my resident spoke up before everyone left and asked if we could go over the patient I was to present really quickly so I was able to give my presentation. Not that I especially wanted to talk in front of everyone, but after putting so much effort into preparing I would have been a little miffed at not presenting.

I have tomorrow off, I am very excited about that. I might not get out of bed at all (one thing I have learned on this rotation: it is a bad sign when instead of feeling sorry for patients you feel envious of them since they are always in bed when you see them—one of the residents mentioned that one of the patients spent 70% of her day at home in bed and my first thought was “that sounds great”. It is also a bad sign when the nurse practitioner stomps through the room loudly saying “I’m going to shoot myself if this pager goes off again”]). The only problem is that I have to work both Saturday and Sunday next week, but usually we are out by noon on the weekend so it shouldn’t be too bad. The weekend after marks the end of this rotation—it has gone by very quickly. Next is cardiothoracic surgery, but there will only be one other student so it is unlikely that I will be getting full weekends.

More surgery

2006-09-08T17:41:00.000-07:00

Yesterday I might as well have stayed at home. There were only two surgeries scheduled, and it was the other two students' turn, and there was no clinic. I rounded on our patients for about 40 minutes in the morning, then went to school to study for several hours, went back to the hospital to check in on things, then studied in the work room for several more hours. When I was about to die from boredom I was finally able to go home. I just hate having to sit around with nothing to do, it drives me nuts. I can do nothing at home a lot more comfortably than doing nothing at the hospital. Adding to the problem was the fact that due to Bible study the night before I had only gotten 5 hours of sleep in--lack of sleep always puts me in an unpleasant mood.

Today was a bit better, much due the fact that I went to bed at 8:30 last night so I got a little more than seven hours of sleep. This morning I was in three short procedures, all dealing with an unpleasant part of the body (I am so thankful I was not the patient in all three of the cases). We didn't have to scrub in because the procedures were not sterile, and because there was not a lot of room I didn't really do anything other than watch and write the op notes. I will spare the details of the procedures, but one of them required a lot of suction and the circulating nurse's applying wintergreen fragrance to each of our surgical masks.

The cases were done before noon, and there was no clinic today, so again I and one of the other students sat around with nothing to do for a good long while. Later in the afternoon the intern had to admit a patient so I went with him and wrote up the history and physical (much shorter in surgery than in medicine!). Then I was able to go home.

Since as far as we can tell (we asked the senior resident, but she just made a joke and didn't actually answer the question) only one of us has to come in each weekend day, we each should get one more full weekend off this month. I was going to have it next weekend, but was paged when I got home to find out it will be tomorrow. I would have preferred next weekend, because taking this weekend off will mean I have to go three straight weeks without a full weekend, but hey, I'll take what I can get. We have actually gotten off a lot easier than the students on this rotation the month before us, they were working 75 hours a week, we have really only had to be there 10-12 hours a day. I still think I am interested in surgery as a career, most of the things I dislike about this rotation (not having anything to do, having to figure out how clinic works with four attendings, not having anything to do, etc) are only issues I have to deal with as a student, and will not be things I have to worry about as an attending. That is one of the hard things about being a student, one doesn't really get a realistic idea of what we will be doing for most of our lives, we just see what it is like to be a student and observe a little of what it is like to be a resident, both in an academic setting which I think is misleading.

There is not much going on aside from medical things. I have been reading a book about the Tudors. One of the things that struck me as interesting is that aside from the fact that all the royals marriages were arranged, the parents of the bride never seemed to have attended the wedding--they just shipped their daughters off with entourages. I guess what with not having as fast travel times back then it makes a little bit of sense, but come on.

Surgery

2006-09-06T15:25:00.000-07:00

Yesterday I scrubbed into my first surgery. It was very neat--it was an ileocecal resection on a patient with Crohns disease (an inflammatory bowel disease). Basically, the surgeon removed about a 20cm section of small bowel. I got to the OR late (because I thought the resident was going to get me when it was time and she assumed that I knew how and when to go down there) and they had already opened, but once I got there I got to scrub in and gown up. My main job was to hold back organs with retractors and to suction any intestinal contents that emerged from the severed small bowel. It was really interesting, although I have no idea how the surgeon distinguishes what parts of the bowel are where. At the end they let me suture up half of the incision with a subcuticular suture (one sutures side to side so that the suture never comes above the skin and is thus not visible) which I had fortunately learned how to do on a pig's foot that morning in our suture lab. I really enjoyed being in the OR, it made up for the all the confusion involved with this rotation (ie feeling like everyone expects you to telepathically figure out where to be and what to do, although I'm sure that feeling which will ease in another week or so). I can see myself wanting to do this as a career.

I went to bed at 8:30 last night, and had to get up at 4:00. It was darker when I left the house than when I went to bed. I pre-rounded on the patient I had been in surgery with, rounded with the residents, then had lecture from 7:00 to 5:00. Fortunately there was nothing to do afterwards. Tomorrow I again have to get up at 4:00, but the other two students will go to the scheduled surgeries (there are far less than I expected, I thought we would all be in the OR most of the day which is not the case) and I'm not sure if there is clinic so I will probably be doing a lot of reading (for some reason it's called "reading" from third year on instead of "studying"), hopefully I'll be able to go home early. I really hate just sitting around with nothing to do that I can't do (more comfortably) at home. Tonight I have Bible study, which means I won't get to sleep until late--hopefully I'll be able to crawl out of bed when my alarm goes off.

Surgery

2006-09-02T17:41:00.000-07:00

Yesterday was my first day of surgery. I had to get to the hospital by 6, so much of the day is a daze. I have two other students on my team, an intern, and two senior residents. We rounded on our team’s patients with the residents, then went to orientation at 8. We got the standard orientation spiel giving information about grading and what-not, then had to get access badges from security so we can get into the OR. At noon, we went to OR orientation which consisted of scrub nurses teaching us how to scrub in and put on gowns and gloves while keeping everything sterile. It is a lot harder than you would think, and I have no doubt that I will violate the sterile field and have to re-scrub quite often. After two hours of this, we went to surgery clinic. I saw one patient who was there for gallstones. The doctor sent me in to talk to her for ten minutes. The first seven consisted of her telling me about her back problems—I was finally able to extract some incredibly vague and dubious information about some abdominal pain that she had a year ago and was coming back. Then the doctor came in the room, and I had virtually no information to give him. Fortunately, he didn’t ask for it and just started talking to the patient who almost immediately started telling him about her abdominal pain. Grrr… He still had to talk to her for almost 45 minutes to explain everything to her though, I was very impressed with how nice and patient he was with her. At the end of the interview, he mentioned to her that he had an aunt whose married last name was the same as hers. It came out that they were second cousins by marriage, and they started talking about Aunt Josephine and various relatives. It was one of the most bizarre moments of my life, for a minute I almost wondered if the doctor was making it up to boost her confidence, but it became clear that was not the case. After that, we went and rounded on our patients again (we students were starving since we hadn't eaten for 12 hours), and the residents told us that since there are no scheduled surgeries or clinic over the Labor day weekend, only one of us would have to come in each day. I went in today, so I get tomorrow and Monday off! That was totally unexpected, but definitely not unappreciated.

I went in this morning at 7:30 (I had to go to bed last night around 9 since I got up at 4:30), I didn’t have to pre-round because I won’t have any patients to follow on my own until I am in on a surgery. I looked up all the labs on our patients (this hospital’s computer system doesn’t even come close to the VA’s), and rounded with the intern and one of the residents. I came home at noon.

This will be an important two months for me since I am interested in surgery—hopefully by the end I will know for sure whether I want to pursue it or not. It is difficult though, because there are so many factors that go into each rotation. For example, I really enjoyed last month, but it wasn’t necessarily because I like internal medicine, it could be just because I had a really great team. If I do/don’t like this month, I will have to figure out if it is because I do/don’t like surgery, or if it is some other factor. My senior resident told me that she originally wanted to go into family practice, but by the Thursday of her first surgery rotation realized she wanted to do surgery. I think the main thing that would turn me away from surgery would be the lifestyle, but while it can be bad, I’ve been told that there is a group of surgeons around here who only work four days a week and only take call every sixth weekend. I think that would be very doable, one would just have to get through the 5-7 years of residency.

Official last day of medicine

2006-08-31T14:15:00.000-07:00

This morning we took the shelf exam—it was the most ridiculously hard test I have ever taken in my life. Only one person left before time was called. The pass percentage is determined by the national average—hopefully it will be really, really, low.

Tonight the Christian group is having its welcome barbecue for the new first years. I can remember that when I went to it as a first year I thought the third years were so unbelievably far ahead of me—now I am one, crazy. Afterwards my Bible study group will meet to discuss Daniel 8—I’m going to have to read up in Matthew Henry before I go.

I thought I didn’t have to go to orientation tomorrow until 8, but when I got home I had an email waiting for me that said my residents want to meet the students at 6. I guess it’s a good thing that they want to meet us beforehand, but I am not looking forward to getting up at 4:30. I called the senior resident to find out where to go after orientation, and after telling me just to page him tomorrow when we are done with orientation, he said something about the 2nd year residents being gone for the weekend, and how it was just him on 24 hour call. Before I hung up, he told me to enjoy the weekend (???). Are we seriously going to get the weekend off? That would be unbelievable, and totally not what I expected from surgery! Although really I would just like to get started right away, but I suppose I should enjoy little breaks in my schedule when I can because I sure can’t expect them to come regularly. Of course he might have meant something different, so I will go in expecting to work the weekend.

I also had an email informing third and fourth years that now that the new parking structure is built, we can park in the coveted lot right across from school (which I have craved and longed for for the last two years). The only problem is that the lot we used to park in, while being an absurdly long walk from the school, is actually considerably closer to the hospital. Nuisance. So the first and second years hate the lots they’re in, and want ours, and we kind of want theirs. Oh well, the price of status I suppose (it’s kind of funny, when I walk through school, or go to the library, I am now one of the most senior people—as soon as I enter the hospital I am lowest of the low—weird contrast).

Transition

2006-08-30T19:08:00.000-07:00

Today was my last day at the VA. In a way I am ready to move on to something else, and in a way I am going to miss it. I got my last two patients on Sunday, one was an 87 year old man with abdominal pain. Turns out he has some small bowel obstruction, but no one knows why. The most common cause is a side effect of surgery, but he has never had abdominal surgery. We discharged him today and he will follow-up with GI as an outpatient. The other patient was a 75 year old man with COPD, coronary artery disease, and a newly diagnosed recurrence of squamous cell carcinoma in the right middle lobe of the lung. He was scheduled to have a triple bypass and tumor removal on Friday, but came in with a severe exacerbation of his COPD. We started him on steroids which helped him a lot, in fact he is being discharged today, but he won’t be able to have the surgery. My attending thinks he shouldn’t ever get the surgery since his risk is so high, and he could definitely be right.

This morning I rounded and wrote notes on my patients for the last time. I had evaluations with my attending, who said I did a good job and brought up the suggestion that my personality is probably more compatible with internal medicine than surgery, though he didn’t want to dissuade me from surgery if that is what I want to do. This isn’t really a surprise, I’ve known for a long time that most students interested in surgery are a lot more out-going than I am, and I definitely do not fit the stereotype of the typical surgeon. He could be right, maybe when I do the surgical rotation I won’t like it, but he could be wrong too—I’ve met easy-going surgeons. Should be interesting.

Tomorrow morning I have my shelf exam, then I have the afternoon off. The Christian Medical Association chapter at my school is having its welcome picnic for the new first years in the evening, and then my Bible study group will meet afterwards. Then Friday morning I will start surgery at my school’s main hospital. I’m hoping that I get at least one day off this weekend.

Field trip

2006-08-25T17:05:00.000-07:00

Yesterday while I was on my break the other medical student and her intern discharged all my patients! The DVT patient was accepted to the domiciliary (Yes!!!), and he finally decided to give himself shots, so he was able to leave this morning. Since most of our patients are gone, we didn’t really have anything to do this morning, so our senior resident took us on a field trip. Basically we wandered around the hospital looking for interesting things to see. We stopped by physical therapy and watched one of our patients do leg raises, stopped by dialysis and watched patients hooked up to the dialysis machine, and lastly went by the pulmonary lab to watch a patient getting a pulmonary function test. After sitting around, eating lunch, and going by the VA store (a bizarre collection of sales tax-free candy, TVs, MP3 players, coffee makers, T-shirts, games, etc) for candy, our attending stopped by and lectured to us about mechanical ventilation which was interesting because I have never had a lecture on it before. Around 2:00, we got a patient from the ER who had been having abdominal pain since Monday, most likely he has an obstructed bowel. He will have to be seen by surgery, all we can really do right now is give him IV fluids since he hasn’t been eating or drinking much. He is a really nice 87 year old man which is a nice change from the unpleasant patients I’ve had recently.

Before I left, the attending dropped by again and asked if we wanted him to bring pizza on Sunday (call day). We all started to hem and haw and politely indicate that if he really wanted to we would love it, but the senior resident just came out with a loud “heck, yeah!” Unfortunately, I have to work on Sunday, but I am really excited to get tomorrow off—I will be able to sleep in as long as I want for the first time this month (and probably the last until my golden weekend [medspeak for Saturday + Sunday—how sad is that that we need a special term for full weekends] at the end of September). The only problem is that now I'm so used to having to get up I'll probably wake up at 6:00 and not be able to go back to sleep.

I have to take the shelf exam on Thursday, then I will start general surgery on Friday—I’m looking forward to it, but one of my friends was on the same rotation last month and he had to work 75 hours a week—I’m hoping that I will have slightly more lenient residents.

More call

2006-08-24T10:11:00.000-07:00

Yesterday we were on call—we had lecture from 1-5 though, so I missed the first patient my intern got and only saw the second. He is an LPN at the VA hospital I am rotating through, and was admitted to the hospital for shortness of breath and bloody cough in June. He was treated with several antibiotics, and improved within a couple days although no one was sure exactly what was going on. They let him leave with two weeks worth of antibiotics. They had taken three sputum samples from him and were going to culture them for acid fast bacteria (includes species such as the tuberculosis bacterium), but these bacteria take months to grow out. Two days ago, one of the cultures came back positive, so they called him back in and he was put into isolation. My intern and I went to the ER to see him and had to gown up and put on special masks. He didn’t have any symptoms except for worsening shortness of breath. We admitted him, and this morning the pathologists said that he does not have tuberculosis so he was able to come off of isolation.

I didn’t see my other patient (DVT and blunt affect) this morning, but he is doing fine. He wouldn’t have to be in the hospital if he was willing to give himself two shots of anticoagulant for a couple days until his oral medication kicks in, but he is afraid of needles so wasn’t willing to do that (so instead he has a constant IV, and gets four blood draws a day). We would be able to just have him come into clinic for shots, but he is living out of his truck so we couldn’t safely discharge him. He has an appointment with the VA domiciliary, so hopefully he can go there and continue treatment.

The resident let me leave today after I had done everything necessary for my patients--unfortunately I have to go back for a case conference in a couple hours, but at least I had time to get my haircut and finally get a blended coffee (different coffee shop, but this time I specifically asked if they could make "ice-blended" coffee) which was very good. My barber told me that he had just been in the VA for 8 weeks for pancreatitis--fortunately he was very happy with the care he received since it would have been a little awkward for me if he wasn't.

Short call

2006-08-22T16:07:00.000-07:00

Yesterday we were on short call (we take new patients until 4:00). I got two new patients. The first patient was a 49 year old man who literally has absolutely no facial expression whatsoever (“blunt affect” is what I wrote in my note) who came into the ER complaining of a swollen and painful right leg, the classic sign of deep venous thrombosis (blood clot in leg). Ultrasound confirmed this. He has also had pain and numbness in his feet for the last four years for which he takes ibuprofen. He hasn’t seen a doctor in eight years since he had his first DVT. Since he has had two DVTs, and his uncle had one, most likely he has some medical problem that makes his blood clot more easily, meaning that he will have to stay on warfarin (originally used as rat poison) for the rest of his life.

My other patient was a 75 year old man who was brought in from a nursing home due to fever and confusion. He has a recent history of pneumonia and has a urinary tract infection, so we have to put him on medications that will cover both infections. The nursing home gave him a lot of IV fluids since he hadn’t been eating or drinking much, which caused an exacerbation of his heart failure, so we also had to start him on diuretics to get rid of excess fluid. Now we just have to watch to make sure he doesn’t go in the opposite direction. When I went to see him he was very lethargic and couldn’t do more than open his eyes for a couple of seconds before going back to sleep, so I couldn’t get a history from him, meaning that I had to search through months worth of notes on the computer. The physical was pretty poor as well, I couldn’t hear his heart or lungs well since he was snoring so loudly. This morning he was a little more alert though, so I was able to hear them all right. Hopefully he will get even more alert so we can start feeding him and giving him his oral medications (he’s on exactly thirty medications altogether) again. Reading through his records he seems like a character—often yells at the staff when they tell him he shouldn’t smoke/go outside in 100 degree weather/etc, and there was apparently a “hit and run” incident in which he (I hope) accidentally ran into another nursing home resident with his motorized scooter and just kept on going. For some reason I keep getting patients who are while not actually mean or rude, do not exactly add sunshine to my day either.

Nothin' to do

2006-08-19T19:00:00.000-07:00

Today I was expecting to be really busy because my team was on call. Turned out not to be the case. I went in at 7:00 although I only had one patient to round on and our attending wasn’t going to come in until the afternoon to see our new patients. I went to see him (the grouchy guy who had the G tube put in yesterday), he was doing fine so it took about 5 minutes to write a note on him. I talked to his night nurse for a minute, then later his day nurse called me with a question about his medications and let me know that she was going to write up the night nurse because apparently she didn’t give him his antibiotics and let him go without fluids all night. Then I heard a really sad story from the other medical student about one of her patients—essentially his wife was coming in to tell him she was leaving him, then taking off on a plane to go to another state. In addition, the man had called the police last night to ask them to arrest his daughter because she didn’t bring him his clothes in the hospital. He also called her and threatened to call the fire department and have them break down her door. He also happens to be for all intents and purposes disabled, and cannot go home (in another state, not the same one his wife flew to) by himself. I read the nurse’s note giving all the details, it was about 20x longer than any nurse’s note I have ever read. Very, very sad; and very, very bizarre (actually there are some even more bizarre details that I am leaving out). It’s hard to believe that things like this happen in real life.

Around 10:00 we went to see the autopsy on my patient who died yesterday. It wasn’t really as hard to see as one might expect because the body is so completely dead. It’s distasteful, and I definitely would not want to see an autopsy every day, but I didn’t really have any particularly strong emotions watching it—the patient was gone, it was just the shell that remained and we could see what caused the patient to leave by examining the shell. The findings were pretty much what we expected, although they didn’t prove that the patient died of TRALI. The blood bank is going to have to examine the blood that he got, and it could take weeks to hear back from them. Further research: about 15 people a year die from TRALI, it occurs in about 1/5000 blood transfusions, and about 5% of those people die.

After that, we still weren’t getting any new patients, and we had taken care of our old ones, so we sat around eating donuts for a while, read up on medical stuff, had lunch, then decided to check out the new resident’s lounge. No one knew where it was because no one’s ever had time to go there, so we went to the right floor and wandered around looking for doors with code panels. We tried a couple, then found the right one. Hoping (but not expecting, this being the VA) for a nicely furnished comfortable room with a big screen TV, soda machine, cappucino machine, video games, etc, we found more what we expected: a barren room with old chairs, a small TV from the early ‘90s, and a couple year old trashy celebrity magazines. We watched some movie on TV about a surfer who starts figure skating for a couple of hours while the resident, intern, and other student (I ended up being the only male there) read the magazines and gossiped about all these different celebrities and movies I have never heard of. It was very weird, no one hearing them talk would guess that their IQ and education level puts them in the top 1% of the nation.
At last, we got a patient. I interviewed him and did a physical exam, then wrote it up only to find that we were admitting him to Heme/Onc meaning he won’t be under our care anymore starting tomorrow. Leaving me with one patient who’s going to extended care on Monday. At least I got to see a patient though, the other student never did because no more patients were admitted—so basically we kind of wasted a day. While I was writing up my H&P the other student went out to get pick up dinner for everyone. We finished off the day with a blood draw on a really nice lady with cancer—thankfully, I got blood on the first try so we didn’t have to torment her too much. Then we got to go home a little after 7:00 instead of having to stay til 10:00. Boy does time go more slowly when one has nothing worthwhile to do. I guess we should really enjoy days like this when we can.

Update

2006-08-18T13:17:00.000-07:00

Yesterday was short call. I did an H&P on a new patient who came into the ER because he claimed to have taken four times his usual insulin dose because he was frustrated by having high blood sugars for the last week. He said that he felt confused and lightheaded. Only problem is that his blood sugar in the ER was 397 (normal 80-120), making it highly unlikely that he had actually taken insulin. He had an extensive psychiatric history of depression, borderline personality disorder, alcohol abuse, cocaine abuse, and participated in a daily program through the VA. On Monday, he claimed that the program kicked him out after two years, and he was really angry at first but now he “just didn’t care”. We consulted with psych, and what actually happened was that he skipped the participation part of the program and just showed up for lunch, so they asked him to leave for the day, but he could come back the next day. So, the most likely explanation is that he wanted attention so pretended to have overdosed himself. He’s medically stable though, so we were able to discharge him today.

My UTI patient had his Gtube put in today instead of having to wait for Monday, so we should be able to discharge him to extended care after the weekend. Oddly enough he’s been quite a bit more cooperative over the last couple of days.

My nice patient died. It was a really sad situation—yesterday he improved considerably, and we were getting ready to bring him back to the regular floor from the ICU—his family saw how much he improved and thought that he had gotten completely better, they were laughing and called us “miracle workers”, unfortunately they didn’t know how inaccurate that title is. Most likely he had a bad reaction to the plasma transfusion called TRALI that occurs in 1/5000 transfusions. I came in late to the hospital because we had lecture this morning, I looked in the computer to see his labs, and then went down to the ICU thinking he would be awake and even better than he was yesterday. When I got down, my resident and attending were writing the death note. Later in the day, we all went down to see his son and daughter-in-law who were in the room with the body. They were both crying and making comments about how they wished they could have been there, but they thought he was getting better. They immediately agreed to an autopsy, because they thought that he would want one so we could learn if there was some way we could avoid outcomes like this in the future and maybe save another patient’s life. The autopsy will be tomorrow, and my attending asked the pathologist if we could watch it. I’m not looking forward to it, but I feel like I should see the whole thing through. I never talked to him about his religion, but I saw on his chart yesterday that he had listed himself as Baptist—I hope that is true.

Attending switch

2006-08-16T16:05:00.000-07:00

Yesterday my team was on call. I spent a long time getting and writing up an H&P on a new patient, then he was transferred to Heme/Onc (cancer doctors) so my entire H&P was basically a total waste and now I don't have a new patient. Oh well. He was kind of interesting, he was an elderly man with stomach cancer that had spread to his liver. He was sent to the ER by his primary care doctor because he had a temperature of 103 degrees. He didn't feel sick and had no symptoms other than a little abdominal pain he's had for months. That morning he felt cold, so he got into his car and turned the heat up full blast then fell asleep for two hours (it was over 80 degrees outside yesterday), woke up, and could barely walk. Then he drove to his doctor's appointment.

Today we got a new attending so things were a bit disorganized as he tried to catch up on all of our patients. He does things a bit differently than our old attending which might be hard to get used to, but it should be a good learning experience to see different styles. He wanted to round this morning at seven, so I had to get there at six--I was not a happy camper this morning, especially since I didn't leave the hospital until after nine last night. Tomorrow I don't have to be there til seven though, so I should be able to manage that.

My patient with the UTI (whom I mentally refer to as "Oscar" [think Sesame Street]) should have had a tube put into his stomach for feeding purposes a long time ago since he can barely swallow and probably has pneumonia from inhaling food, but along with breathing treatments and heparin shots has refused it. Problem: he needs assisted living and they will not take him without a G tube. My intern basically told him point blank that he will either get the G tube and go to assisted living, or slowly starve to death in the hospital, so he finally agreed. I had to convince him this morning to let the nurse put in an NG tube (goes through nose into stomach) until the radiologists put the G tube in. We'll see how long he keeps it in--I'm sure I'll hear about it tomorrow morning.

My other patient, the one with ascites and pleural effusion, is not doing well at all. It looks like he has developed severe pneumonia, he had to be moved to the ICU this afternoon as his oxygen saturation went down to 70% (normal is above 97%). The resident doesn't think he has much longer.

On a lighter note, I have been looking forward for days to getting an ice-blended coffee since I have not had one for months and I seriously need sugar and caffeine these days. I had it all planned out how I would try a coffee shop I have never been to before right after lecture today, and have dreamed about the creamy, sweet, cold taste all week. So today I went there, but couldn't see anything like what I wanted (frappucino equivalent) on the menu, so I asked the guy behind the counter if they had blended coffees. When he seemed really uncertain, and mentioned he had never heard of a frappucino I should probably have seen a red flag. He pulled out the list of ingredients for their different coffees, I saw a caramel one, asked if he could make it blended, he said yes, so I said I'll have that. He proceeded to make a regular hot coffee and gave it to me. There was a line forming behind me, and he seemed really new and not very self-confident so I didn't have the heart to tell him that it was the opposite of what I wanted (this was my good deed for the month). It tasted pretty bad for a hot coffee too. I almost drove to another coffee shop I had seen, but decided that paying eight dollars in one day for one coffee was not a wise use of my money. Maybe tomorrow. Or Friday. Lesson: Don't count on worldly material things.

Blood II

2006-08-14T14:17:00.000-07:00

This week started off a bit easier than last week, I got to go home at 2:30. We haven’t gotten any new patients since Friday (but we’re on call again tomorrow), so we just had to take care of the ones we’ve had for a couple days. The man with the UTI has become a real grouch (well, when I say “become” I actually mean “become more of a”--every morning I've gone to ask how he's feeling he looks at me like I'm an idiot and says "well I'm in the hospital, you should tell me"), he won’t let respiratory therapy give him breathing treatments and he won’t let the nurses give him his heparin shots that he needs so he won’t get clots in his legs from lying in bed all day. He also refuses to take oral antibiotics so we have to keep him on IV. He’s stable though, so as soon as we can we’re sending him off to transitional care.

The pleasant patient with the pleural effusion/ascites shocked everyone today by coming back positive for hepatitis C—we had just ordered the test as a formality since he doesn’t have any risk factors for it other than several blood transfusions decades ago. Unfortunately, this makes the likelihood of his having cancer even higher. He was supposed to get an ultrasound guided paracentesis today, but his liver function has decreased his clotting ability so the radiologist won’t do the procedure. We’re giving him vitamin K shots to get his clotting back to the point where he can have the procedure. He’s also getting a CT scan which should show any tumors (I think).

The man with the bacteria in his blood has to have blood drawn every day until his cultures come back negative, so I jumped at the chance to draw it today. My intern said I could do it unsupervised now that I’ve done it a couple times. I got all the stuff, got the front desk to print out the labels, and set up the stuff in his room. I found a vein in his left arm, went for it, got blood on the first try, and with needle in my right hand and syringe in my left in one smooth, intricate motion that was beautiful to behold got 20cc of the precious fluid in under a minute. Then I went to the right arm… Poor Mr. “G”. I tried twice to get the needle into a fairly prominent vein with no success (well, actually he did bleed, but unfortunately not into the needle). Crumpled with failure, and shoulders slumped under the blow of defeat I went to get my resident. But then she couldn’t do it either, so while I felt really bad for Mr. G (who remained placid through the entire ordeal), I felt a lot better about my own (lack of) skills. We had to get the IV team (nurses who spend their entire day doing nothing but sticking people) to come, and it even took them a couple tries although they eventually got 12cc which was just barely what we needed (to clarify this story, for blood cultures one must get blood from two different sites). They left him with a nice egg-shaped mass on his arm.