Surgery Oncology

Yesterday I started on the Surgery Oncology service. I was thrown straight into the fire. My first 2 surgeries yesterday were 1st a mastectomy and then an excision / removal of a large synovial sarcoma. As you can imagine, all of the surgeries on this service have to do with removing cancers / tumors. It is an interesting aspect of surgery. Often you are able to offer a complete cure for the patient.

The synovial sarcoma surgery was on a 22 year old female who originally presented to her primary care physician with a complaint of pain behind her right knee. When her doctor palpated the popliteal fossa (are behind the knee) he felt a suspicious lump. She received some imaging studies and it was determined that the suspicious mass needed to be biopsied. She was referred to the surgery oncology team and they performed a fine need aspiration and confirmed the diagnosis of sarcoma. She began a course of 8 weeks of focused radiation to shrink the large mass. She just finished the radiation therapy 1 week ago and the mass had shrunk. Yesterday we removed the mass.

It was a difficult surgery as the tumor was tangled in vessels and nerves. It was tedious to remove the tumor while trying to preserve the nerves that had been enveloped in the tumor. A potential complication of this kind of surgery is nerve damage that leave the patient with paralysis of her foot and or leg. There was no way to preserve every nerve but we were to keep all the major branches. After the surgery and again today we were able to confirm that here motor and sensory abilities were spared in the surgery. We did have to cut a few small branches of some nerves but it appears that by sparing the major branches she was able to maintain normal function. You never know for sure how much function will be maintained or lost during the surgery so we were pleased with the initial results. We were able to remove all of the tumor so this procedure is considered a surgical cure. However this cancer does have a high rate of reoccurrence and given that she is so young there is a high likelihood that the cancer will come back. If or when it comes back it usually is much worse the second time and often fatal. 

Tomorrow I will be in on 4 mastectomy cases. Today we had breast clinic all day. I saw about 25 + patients who were suspected to have breast cancer or in various stages of treatment for their breast cancer. I had to be the bearer of bad news to 5 different patients today and tell them that they had cancer or that their cancer had returned. This is a difficult task and there is lots of tears and questions as the patients life is derailed. It is a surreal experience to be sharing in that experience (in a detached way) with the patient and their family. I also had the opportunity to tell several patients that they did not have cancer and I was able to celebrate with them as gave them the good news. It is strange to leave one patient sobbing and scared for their life to go to another patient who is so elated by good news that all they can do is cry for joy and hug you. 

The good thing about this rotation is that by the end of it I will have performed enough breast exams and felt enough breast tumors that I should have no problem identifying abnormalities in my future patients. This is where you get literal hands on experience that is so much more valuable than reading about it in a book. This is where most students perfect their breast exam skills. Even after one day of clinic I already feel much more adept at performing breast exams. I hope this is not considered petting.

Appendectomy

Today, Saturday was a great day. I added another procedure to my bag of tricks. I showed up at the hospital to at 6:30 am, my resident said I could come in late because it was Saturday, and I rounded on our vascular patients in the surgical ICU (SICU). It was great to see the Polish patient because he was doing so well. This was the guy who we had done several procedures on in an attempt to save his leg. This was the first day that he and his family were all smiles. His leg looked good. There still is a good chance that the grafts could fail, but there is also some hope as he appears to be doing well and we were able to get some pulses in his foot.

What do I do when I "round" on our patients. I check their surgical wounds for infection and change the dressings. I review how they did over night with the SICU physician. I look at their latest labs and medications and make any necessary changes. I usually run all of my thoughts by my resident. For example today one of our patients blood tests revealed that she was at risk for bleeding  so I lowered her heparin (anticoagulant medication used to prevent strokes). 

After seeing all of my patients I got paged for an appendectomy case that had presented to the ER. My chief resident and I made are way to the patient to examine and confirm the diagnosis of appendicitis. Sure enough she had appendicitis so we cleared an OR and made our way to the surgical unit to do an appendectomy. This was a great procedure and because it was Saturday the attending did not want to be bothered so he let us do most of the case. It was great to see this procedure and to be able to help do it. We did an open appendectomy through a 4 cm incision. It is a rather quick procedure and there are a handful of pitfalls to avoid but it was relatively easy. The appendix was in fact about to perforate so it was good that we did the procedure before she perforated as this causes a lot of extra complications. 

After I finished today I was actually disappointed to be leaving the hospital. I wanted to get home to see my girls but this is the first job where working on a Saturday seemed enjoyable. Hopefully this feeling sticks around for a while.

Harvesting veins is fun to do, fun to do, Harvesting....

Today I got home before 8:00 pm! I have way too much to read and I have to be in the hospital by 6:00 am tomorrow. I must say that I am having a good time despite the hours. 

The pictures above are of me and my chief resident harvesting veins for the procedure. The attending took these pictures on my Iphone. I did not realize he was taking the pictures and after the case he said "I left you evidence on your Iphone so you can prove to your wife that you really were in the OR and not on a date." I responded by asking "does this work for you with your wife?" he said "no! this  is why I am on my 3rd marriage!"  If you click on the pictures they will enlarge and you can kind of get a better idea of the scene. Really I just want you to see how cool I look (all 3 of you that read this blog occasionally) and you can do this much better is you enlarge the pictures by clicking on them. 

Let me tell you about today's surgery. The patient is a 58 year old gentleman that has made his living as an accountant. Last May he injured his foot and it would just not heal properly. He spent several weeks agonizing over the pain and hoping that the ulcer (wound) would heal but it never did. In fact it got worse. Finally because the pain and the smell were bad enough and his family begged enough he finally decided to go to the ER one early morning at 3:00 am. The ER doctor took one look at the foot and knew this was a disaster waiting to happen. He could not find any pedal pulses which made him even more discouraged about a good outcome. He tried to explain to the patient that he most likely needed surgery which included an amputation. 

So the man was referred to the Vascular surgery team. When the surgeons later saw the foot they were excited to operate and believed that they could fix the problem. This patient had a history of smoking, drinking and eating like Elvis. These talents brought him vascular damage and a whopping case of atherosclerosis that had not ruined his heart yet but had done some fairly decent damage to his lower extremity vascular system. Due to this damage his legs were not properly vascularized and so his injured foot was poorly perfused and could not heal. The vascular team finally scheduled him for surgery in June with the hopes of salvaging his left leg and foot.

In June they performed a "fem pop" with a graft. So they opened his femoral artery around his groin and sewed a gortex graft into the blood supply and then took the graft to his popliteal artery right behind his knee and connected it there. This bypassed the bad vessels in his thigh and restored blood flow to his calf and foot. The surgery went well and the patient's leg / foot began to heal. The family which is fairly extensive was excited that they would not have a gimpy father / grandfather. You would think that this would be the end of a happy story. You would be wrong.

Now fast forward to last week. The patient has horrible throbbing pain right behind his left knee and his lower leg and foot look like a cadaver's leg. His family dragged him kicking and screaming back to the hospital and the vascular surgery time. This is where I meet the patient. Now that I am on the vascular team I get to see the patient. I can tell as I walk into the exam room and read through the patient's chart that I will get to be in on and maybe even do some surgery. I examined him and used a doppler ultrasound but I could not find any pulses in his lower leg which means there is problems. My chief resident then examines the patient and concurs with my diagnosis and we schedule the patient for surgery on Wednesday 9/24. 

On Wednesday in the OR we opened his legs and we soon realized he had an infected synthetic graft. Lots of pus flows out of the graft. For the next 12 plus hours we painstakingly removed all of the infected graft and followed it up from the knee to the groin until we were able to find areas that were clean (no infection). This took so many hours that we had to stop the surgery. We were were able to restore a little flow to the lower leg but the work was not done. Today we went back in and harvested the saphenous vein from his right leg which took several hours. Then we used this vein which can also be used for bypass surgery of the heart and we reversed the direction. You have to reverse it before you graft it into the bypass because it has 1 way valves. The saphenous vein normally brings blood back to the heart from the lower extremities but now we were using it in a bypass procedure to bring blood from the heart to the lower extremities. If you do not turn the vein around the graft will flow the wrong way and your graft will fail. This must also be done when you use this vein to bypass the heart. We harvested the vein and flipped it around and attached it to the femoral artery in his left groin and ran it past the knee (behind it) and to the lower calf. It was a below knee (say below knee fast and it sounds like bologna) to the lower calf human graft. By doing this we were able to restore the flow to the lower leg and hopefully save this patients leg and foot. 

This was an amazing procedure to be able to help perform. The pictures I included are of me harvesting the vein from his right leg. It is a fairly bloody surgery as we cut up and down both legs. Fortunately I had excellent teachers helping me learn and do my part. It was great to see that as soon as we hooked up the graft and unclamped the blood supply his leg filled with blood and literally came back to life. I also got to close the wounds. I used sutures and staples and this took 1 hour to do, it was great practice. I was able to try a bunch of different suturing techniques. This is how we learn. Now we just have to wait and see and hope that the graft takes and that infection does not ruin it. These next couple of days - weeks are tenuous because at this point if the graft fails he will certainly lose his left leg. It was rewarding to work all day and hook everything up and to be able to feel pulses return to his foot.

At the end of the surgery I had the pleasure of going to talk to his 20 + family in the waiting area and explain the results of the surgery. His wife and daughters almost knocked me over with their hugs as they said thank you. The whole family had been crying / praying for the past few days as they waited for their dad / grandpa to get the surgery and hopefully get better. After talking with the family and explaining everything I had a few new patients to round on. I went and saw the patients and then was able to head home. On the drive home I kept thinking about how fortunate I am to be able to do this kind of stuff. I love it. One day I will actually get paid to do it. 

Tomorrow I start bright and early and one of my new patients is a 25 year old African American male who took a gunshot in the thigh and will probably need a similar surgery / graft procedure as today's patient. However this young gunshot victim may not make it to surgery. He lost a lot of blood and when I went to check on him in the trauma ICU he was barely hanging on. His family was all there and very upset. I did my best to tell them what I knew and explain the situation. One case ends and another begins, every patient has a story and every patient has family and friends who are agonizing over their condition. Hopefully he lives through the night and we get a chance to try and put his leg back together again.

Vascular OR and the bad kidney

Yesterday my day started at 3:30 am and  I did not get out of the OR until 10:00 pm. We a couple of major surgeries, 1 lasted 14 hours straight without any breaks. It was insane. The first surgery was a 54 year old man that had a renal cell carcinoma that grew so large it had worked its way up the inferior vena cava into the superior vena cava and then into the right atrium of the heart. We had a bunch of surgeons in there. Urology was there to disconnect the tumor which included taking the kidney out. Cardiovascular surgeons were there to remove the tumor from the vena cava and the heart. My team was the vascular surgery team lead by our attending physician who is well known in the vascular field. The vascular surgery team was there to repair all of the damaged vessels and make sure that the blood flow was restored and not bleeding anywhere. You should have seen all the bloated egos as the different surgeons had to work together. It was palpable. 

At one point the patient was put on cardiopulmonary bypass which is a machine that takes over the function of the heart. Technically the patient was dead for several minutes as the tumor was removed from the heart and the repair was completed. It was great to get to see all of this and help with this procedure. I got to do some minor cutting and some suturing. It was an intense case. I have included some pictures of the kidney which was nearly the size of a basketball because of the cancer. I also included a picture of the bypass machine. The cool part about this is that the patient survived and is doing well, although he is not out of the woods yet and is still in risk of dying. I think we went through 20 units of blood during the surgery and we had to shock his heart a couple of times.

It was a long, long day but it was also very rewarding. I was tired but totally charged up after the surgeries. The lifestyle may take away from other areas in life. Certainly these kinds of things have to be taken into account as I try to figure out my pathway in medicine. In surgery everyone has loots of long days. All the attendings were there as long as the residents and the students. When we finished the surgery at 9:30 we still had to round on other patients and we had to be back at the hospital at 4:30 am the next day (today). At least I was done today by 7:00 pm. 

Vascular surgery

Long, long days is what I have to say! We start at 4:30am and go until 8:00pm without any real breaks. You have to find time to go to the bathroom. Today was a clinic day. We saw all kinds of patients with vascular disease. Many of these patients have wounds that will not heal on their feet or legs. The wounds will not heal because they lack the proper circulation due to their vascular disease. See the pictures to the right. This is a patient's foot that I treated today. He had a right hallux (big toe) amputation due to an ulcer that turned gangrenous. He needs vascular repair surgery or he will eventually lose the limb below the knee. We are working him into next week's surgery schedule. Many of these patients are diabetic. If they do not receive a vascular repair surgery to restore blood flow they will end up loosing their limbs. 

You can imagine that these wounds that are not healing have some magnificent aromas. Today I had to change so many foul rotten dressing. Once I removed the bandages I then had to asses the wound and debride (cut out) and gangrenous tissue. Then I would write a prescription for antibiotics if there was a true infection. Some of these patients had already had part of their limbs amputated. Some of the ulcers were pretty foul. This type of clinic work is the worst part of the vascular surgeons job. They like to be in the OR like all the rest of the surgeons but inevitably they have to evaluate and follow patients in clinic.

The fun / better part of vascular surgery is life in the OR. What does the vascular surgeon do in the OR? They will do surgery involving vessel repair (arteries and veins) anywhere in the body. Often they will not do the vessel work directly on the heart. The hart procedures are done by cardiovascular surgeons. Often smokers, diabetics and or the aged patient will have vessels that have become occluded. This compromises circulation of blood to vessels which causes ischemia and death of the affected tissue. The vascular surgeon will take the occluded part of the vessel and either put a stent in or replace it with a vessel graft. They do a lot of rerouting of the vessels. Theses surgeries are great and help the patients quality of life by preserving a limb and getting rid of the associated pain that these patients have.

Tomorrow we are in the OR. We have a patient who has a tumor on her kidney that has grown all the way up her vena cava (big vein that carries deoxygenated blood) to the right atrium of the heart. Vascular, Urology (for the kidney) and Cardiovascular (for the heart) are all working together on this surgery. The surgery will take all day and involve many areas of the body. It will be great to see all the anatomy and I should be able to do some of the cutting and suturing. Tomorrow will be a long but interesting / fun day. I have to study up in all of my anatomy and surgical technique for this surgery as I will be grilled and tested throughout the entire surgery. Sometimes if you answer the questions incorrectly or do not know the answers one of the surgeons my kick you out of the OR to go and study. Hopefully we do not have any of these megalomaniac surgeons on the case tomorrow. Even if there is I can usually win them over with some humor and they tend to look past any questions that I can't answer. They keep me around for comic relief. 

Medical consults at church

It seems now at church every week I get asked to see someone for the medical problems. I do not mind it usually but I think that some of the members are a little thrown off when I switch into doctor mode. A few weeks ago I had a 55 year old woman at church ask me about some intermittent pain in her legs. So we went into an empty room and I began my exam which include palpations and several uncomfortable questions about her menopause and and other unmentionables. She answered the questions but I think she was a little surprised. If I am going to be asked to see someone I certainly do not want to miss something so I am going to do a thorough exam. Hopefully no one asks me about a lump in their breast. 

Today at church we had a 3 year old boy who was pulled by his older sister at church and they thought t hat he may have dislocated his shoulder. I was asked to go to the nursery and see what was going on. I explained to the parents that shoulder dislocation in children is rare and a humorous fracture is more common. The boy was guarding his right arm and obviously did not want it touched. So I began to examine him and did the proper maneuvers to determine if it was dislocated and reduce the shoulder if needed. It did not appear to be dislocated so I examined it for other injuries. I explained the finding to the parents and told them it was either a separated shoulder or possible fracture or a strain / sprain. The only way to make a complete diagnosis would be an xray. I at least save the the headache of going to the ER. I told them how to care for it and what to watch for and that if by tuesday / wednesday  the did not see some improvement to take him to a doctor, not the ER. My opinion is that the child most likely has a sprain. He did not have the level of pain associated with a dislocation and  when I tested range of motion his shoulder it was clear that his shoulder was not dislocated. 

It was cool to be able to help. When I was working in the ER I had the opportunity to examine several kids with the exact same symptoms and I used an xray to confirm my diagnosis. I also was able to reduce a handful of shoulder dislocations so I at least knew what I was looking for and how to fix it if it was in fact a shoulder dislocation. It is interesting as I continue my training I am realizing that each patient is an added level of training. There is no easy way to learn this stuff, it just comes over time with lots and lots of exposure to patients with particular illnesses. There are no short cuts just tons of hours seeing patients and studying. 

Emergency Trach

Today was an OR day. I love the OR. Today I had a very interesting experience. The most stressful / exciting to date in my training. We had another Polish patient with suspected advanced esophageal cancer with metastasis. Today all we were going to do was to biopsy the tumor in his esophagus to get an actual diagnosis of his cancer. This was to be an out patient procedure, in and out. The patient was intubated in the OR and we took a couple of pieces of the tumor to send to pathology. We then proceeded to wake the patient up. At this point my chief resident and 2nd year resident left to a consult in the ER. The attending physician was rounding on some of our other patients. The anesthesia attending had stepped out as well as this case was considered very straight forward. In the OR it was me, my 4th year resident, and the 2nd year anesthesia resident and a junior scrub nurse.

We excubate the patient and were preparing to transport him to recovery. He is breathing on his own and doing fairly well. He had some stridor but this was to be expected. Suddenly we notice his stridor stops and all airway noise ceases. Then all of his numbers start to drop. He starts to decompensate. This is where adrenaline takes over. My 4th year resident decides to do run an emergent tracheotomy. As the patient continues to crash, the thought crossed my mind; "holy sh%&^" we are going to lose this guy. Your brain can't survive very long with anoxia. The anesthesia resident was busy running his anesthesia and monitoring the patient and changing settings and pushing drugs to help. The junior scrub nurse was useless and scared. My resident yelled "11 blade" as the scrub nurse just stood there panicked I pushed past her and grabbed the 11 blade scalpel. The resident palpated for proper placement between the thyroid and cricoid cartilage and began to make an incision. I started to cut the tissue straps out of the way to expose the trachea. We lacerated a vein and blood was spilling everywhere to add to the excitement. As I listened to the resident instruction we exposed the trachea and made a laceration in the trachea. Meanwhile the scrub nurse was supposed to be preparing the tracheal tube for insertion but she was literally frozen so when the resident asked for the device it was nowhere to be found which put us in a tight spot as we had already cut into the trachea and I had my finger in the trachea to keep it from moving and to block blood from pouring into it and causing the patient to aspirate. The resident had my grab a suction tube and he cut it and inserted it to my finger and I pushed the tube into the trachea. 

At this point we all anxiously turn to the monitors to see if the patients O2 saturation starts to rise. It will usually take a few moments to start rising once the airway has been cleared. Those few moments felt like hours. Even though the monitors were screaming out alarm calls because all of the patients numbers were at critical levels but for those moments it felt as though everything was silent. I noticed the patient's chest rise and looked to the monitor to see his O2 saturation start to climb. We all let out a huge sigh of relief and slapped some high fives. The floor had blood spilled everywhere and my resident and myself were also covered with blood and sweat but no tears.

I sat there with my resident following the explosion of excitement and it all seemed so surreal. I was thinking to myself; "did this really just happen?" did I really have my finger jammed into this guy's trachea?" It was amazing and extremely satisfying. Surgery is unbelievable. As I drove home from the hospital tonight I was so tired yet I had this feeling of complete satisfaction as I pondered the events of the day. This is so much more fulfilling than anything I have ever done. It sure beats selling mattresses or pushing pharmaceuticals. I am so glad I decided to go to medical school.

Rape, Cancer and a Chest Tube

Early this morning I got paged to the ER with the junior resident to see an emergent consult for a potential orbital blow out fracture with nerve entrapment. We get to the ER to see the patient and get the story. She was intubated, so she could not tells anything about her condition. This was a 17 year old african american female who was found naked and unconscious in the street (south side) at 2:00 am. She had been raped several times and had blunt force trauma to the face. It looked like she was hit with a bat in the face more than once. She was in bad shape. These kind of cases are always terrible and heart breaking. She was a Jane Doe so no one knew who she was and could not contact any family. We looked at the CT scans and Xrays and sure enough she had an orbital fracture. Fortunately there was not nerve entrapment or that would have been an emergency surgery to prevent blindness. We have her scheduled for Friday to repair the orbit and but the eyeball back where it belongs.

Then we had a 65 year old Polish immigrant who presented to the ER with stage 4 metastatic esophageal cancer. It is unbelievable that the cancer has progressed this far and he has had no treatment yet. He came in because the cancer had become so massive that he could no longer breathe. He did not speak any english. We were consulted to put in a tracheotomy but because his disease was so progressed we had to do the procedure while he was awake because he would not tolerate the procedure under general anesthesia. He was used local anesthesia and he was mildly sedated. However in the middle of the procedure panicked and tried to get off the table, he started to decompensated. We had to hold him down and get the trach placed. In the process of him moving around he pushed one of the clamps into the apex of his lung and caused a collapse of the right lung = pneumothorax. 

It was pretty hectic. In the chaos I got to treat the pneumothorax which is done by placing a chest tube. I made an incision in the intercostal space and inserted a chest tube which immediately relieved the pressure and allowed the lung to re-inflate. It was very cool and bordered on rock star, no wonder surgeons get so full of themselves. I quickly reminded myself of all my weaknesses and was quickly brought back to reality. Placing a chest tube in this environment can be real tricky, you have the timing pressure and everyone is watching you, you are trying to make sure you are doing it correctly all while trying to not injure or kill the patient. Fortunately it all went well and I got to do my first chest tube.

Detachable Ear

What a day. Today started at 3:45 am and ended at 8:00 pm. I start up again tomorrow at 3:45 am. Today we were in the OR so it was all good. We had several cool cases. 

We had a 53 year old white male who presented to clinic 2 weeks ago with a chief complaint of pruritis of the left ear. (itchy ear) On examination a small nodule was noticed on the tympanic membrane. We performed an in office biopsy of the nodule and sent it to path. The biopsy came back from path a week later with an ambiguous diagnosis. Basically the pathologist hedged and said it did not appear to be cancer but he could not rule out cancer completely. This means that we had to operate and remover the entire nodule. Today we did the surgery which involved cutting the skin right behind the ear and completely peeling the ear off so that the inner ear was exposed. This was so cool. You could see the anatomy of the ear so well. Once we moved the ear out of the way the tympanic membrane was completely exposed. The nodule was completely removed which damages the tympanic membrane. To repair this we cut out some fascia from behind the ear and grafted it in as a replacement for the tympanic membrane. This was a great surgery.

If the patient does indeed have cancer in the ear we removed the entire nodule so this would be a potential surgical cure if there are no other areas in the body with cancer. Most likely the nodule was benign but the pathologist wanted to cover his tail so he hedged on the diagnosis. This same thing happens in radiology as well. This of diagnosis from a pathologist or a radiologist reduces their liability but it increases the liability for the treating physician. Sometimes the biopsy really is ambiguous and the pathologist is not hedging he / she truly can't tell from the biopsy what the diagnosis is so they have to give an ambiguous diagnosis. 

Dr. Hope

Today in clinic we had a new patient show up with a chief complaint of throat tenderness and a change in voice. Her voice had become raspy. As I questioned her about past medical history and illnesses I soon learned that she had stage 4 tongue cancer in 1996 and had extensive surgery to resect the cancer and chemotherapy. She had beat the odds and had been in remission since 1998. She had come into clinic today with these symptoms for a check up. Her husband came with her.

I figured that I should perform a nasocopy to see if I can seen what is going on with her larynx and throat. As I looked through the scope a frightful landscape unfolded. I saw cancer all around and it was furious. Before commenting to the patient I went to get my chief resident. I quickly explained the case to her and she came in and looked through the scope to see for herself. We both went and found the attending to explain the case. He then had a look for himself. The patient and her husband still did not know anything and sat there clueless to what we were seeing. We left them to discuss amongst our self what we should do next.

I mostly listened to the chief resident and the attending discuss this case. They basically said that this patient was in serious trouble and that the cancer was so far progressed that there was not much hope. The cancer not only returned but it was aggressive. We were discussing the patient in terms of weeks to months and basically they had determined it was probably inoperable. It was a sad discussion. 

Here is the interesting part; we went into the exam room after discussing the patient's impending death and the attending told the patient "we see some abnormalities in your throat and larynx and we can't be sure exactly what it is so we are going to send you to get some imaging studies. This will help us determine is going on." He said this with a smile and turned around and walked out of the exam room. The chief resident basically dodged a bunch of questions and I basically had to remain silent. The patient and her husband left to go get the CT scan we had ordered. I know they were worried but I do not think they have a real idea of how grim their life is about to become.

Why do doctors do this? Is it to provide hope? I have seen this vague type of question dodging and deflecting many times. I have tried to figure out why this is a common practice amongst many  doctors. Not all of them do this but many do it at one level or another. Obviously with today's case once we have the CT scan back and a confirmed diagnosis they will be told what is going on, however there may still be some vagueness in the doctor's explanation. I have to respect the physician's methods as the medical student but I do think about how I will handle these situations when I am an attending. I am sure there is an appropriate way to give the patient some hope while being realistic. I certainly cast no judgement at this point as I am sure my opinions will develop / change as I gain more experience. 

One take away point is that you must be an advocate for yourself as a patient and do your own research about your illness once you get the diagnosis so you can know your prognosis and options. If you arm yourself with knowledge your going to get the most info from your doctor. The more info you have will enable the doctor to better guide you. The doctor will answer your questions but you have to know what questions to ask and sometimes you may need to ask 2 or more times and do some guiding of your own. 

More ENT

I am staying on the ENT service for at least the next week and maybe 2 weeks. The adventures will continue. I was actually schedule to go to vascular surgery for the next 2 weeks but the ENT service has asked me to stay on. This is great for me be cause I like working on ENT and the doctors are great. I imagine that they will give me a great letter of recommendation. 

Tomorrow is clinic and Mondays are usually very busy. At least the 4th year resident will be back from his vacation. We will see all kinds of throat, ear, nose problems. By the time these patients make it to ENT their issues are fairly serious. This is their final stop. In clinic often have to diagnose and give the patients bad news. Lots of cancer or other serious conditions. There are also less serious conditions like hearing loss, compacted ear wax, tonsillitis, etc. It should be a good day.

The thrills of surgery

I just got home. Today started at 4:00 am and it is now 9:00 pm. What a long day but the strange thing is that I loved it which makes the time a non-issue. Today was a surgery day. We had 3 cases.

The first case was a 18 month old female with neurofibromatosis which is a rare autosomal dominant genetic defect. If there is 1 parent with the effected gene, on chromosome 17 then there will be a 50% chance of the offspring inheriting the disease. What is the disease? It usually presents with cafe au lait spots (look like brown birth marks). There are a few different versions of the disease and variable degrees of severity. The most severe presents with multiple tumors, including acoustic neuromas causing deafness and brain tumors. 

This girl's doctors wanted to rule out tumors / hemangioma in the bronchi as she has continually had respiratory problems. We did a bronchoscopy which is a procedure that involves using a camera to explore the bronchi of the lungs and see if you find any pathology. This girl turned out to not have any pathology in the bronchi.

The second case was a 5 month old male infant that was born premature at 26 weeks to a mother who abused crack and drank lots of alcohol. This baby has never left the hospital and is very sick. Most likely this child will expire and if it does survive it will be a  miserable life. The baby has been on a ventilator his whole life and so we were doing a tracheotomy to make the ventilated breathing easier. 

Whenever you do anything medical / surgical with infants it is like working on a time bomb. They are so fragile and things can go bad fast. Plus all the surgical techniques and pharmacology have to be altered. I do not think I would like pediatric surgery or medicine of any kind. To me it feels like you are on the edge of disaster at all times. Both of the pediatric cases went fine but we did have some tense moments. Also it was hotter than Satan's rectal vault in the OR. When operating on infants you have to keep the room very hot because infants do not do well in surgery with added thermoregulatory stressors. If the body has to focus on maintaining normal temperatures the overall system does not do as well and the surgical outcomes are worse.

The final case was an unbelievable case. I was fortunate to be able to see and do part of this surgery. We were doing a resection of a parotid body tumor. The parotid gland is located in the face where last weeks surgery on the carotid body tumor was in the neck. In today's case we had to expose a lot of the neck anatomy but also the face anatomy. We exposed the facial nerve and had to be careful not to damage it. We were successful in protecting the facial nerves and arteries. This case took 6 + hours, it was long. We also had some bleeding issues and it became tense as we had to find the bleeding vessel and tie it off. This took some time and fancy maneuvering to avoid damage to the structures. DUring this time I was working the retractors to move structures out of the way so the chief resident could find the vessel. During this whole time we were battling against blood flooding out. It is amazing how calm everyone stays, which is not the case when doing surgery on kids. Ultimately, after 20 minutes we were able to control the bleeding by finding the bleeding vessel and tying it off.

At the end of the day I felt so charged and this makes me consider surgery. I entered medical school wanting to do surgery but I also wanted to see the rumored lifestyle and see how painful it is. The plot thickens as we look at surgery as an option.

Lectures

Today I had lots and lots of lectures. On Thursdays I have lectures all day. The good thing about the lectures is that I get to see friends from school who doing their surgery rotations at different places. There are about 30 of us. So it is a good time to get together and share stories and get caught up. 

Today's lectures were on breasts and pediatric surgery. A pretty well known breast surgeon gave us lecture about breast cancer and the surgical treatments available. I never thought I would say that I would get bored talking about breasts, but never say never. We basically covered all aspects of diagnosing and treating breast pathology. One of the newer concepts is that with certain forms of cancer they administer chemotherapy first and then remove the cancer surgically. They used to head straight to the OR and then do chemotherapy. However, they have found if they can shrink the tumor first it will require less surgery and does not increase mortality of the patient. Another new concept is that they do not recommend self breast exams anymore. Most of the recent data suggests that self breast exams do not decrease breast cancer mortality and in fact increase the amount of unnecessary surgeries. It is still recommended to get regular breast exams done by your physician. Regular mammograms are recommended after 40. 

We also had a lecture series on pediatric surgery. I do not find pediatric surgery very interesting. We basically covered all the common surgeries seen in kids like inguinal hernias, pyloric stenosis, etc. I would have rather been in the OR learning about these with hands on experience. 

Tomorrow we have 5 surgeries, so it is going to be a long day. I am excited and love the OR. The best surgery tomorrow is a neck tumor removal. This tumor is huge, it is almost as big as the patient's head and highly vascularized. There will be lots of blood which means I will get to tie off lots of blood vessels. It should be cool.

I Like Surgery

Today we had several surgeries. Again it was a 13+ hour day but I am loving every minute of it. We had 2 tonsillectomies, 1 uvuloplasty, tracheotomy and a mandible reduction. Good times! I really like doing surgery and the residents who run the ENT program are more than happy to let me help with the surgeries. I feel like I could work all day in the OR, which is a good thing because that is what they require.

The first case we did today was a 22 year old male who over the weekend found himself in a fight and his jaw was broken into pieces by a fist. So we had to put it back together again and wire his jaw shut. Throughout the entire procedure I kept thinking to myself that his mouth is going to kill for the next week or so. In order to work on the jaw we had to use metal retracting tools to keep his mouth open and his tongue out of the way. You can't be gentle, so we were tugging and pulling and I have to imagine his mouth / tongue are going to be bruised. In order to wire the jaw shut we took wire and pushed it through the gums between the teeth, then you wrap it around a tooth and come back around the tooth through the gums again. It looked painful. I hope to never break my jaw.

The tracheotomy was a sad case. The patient is a 44 year old male with aggressive esophogeal / laryngeal cancer. We were doing a tracheotomy to insert a breathing tube. Basically you cut through the tissue and into the trachea about 2 finger widths above the sternal notch. We then insert a breathing tube. This patients cancer is so advanced that his entire neck is 2 - 3 times normal size due to all the cancerous growth. He is going to die shortly. I was looking at him after the procedure before the anesthesiologist woke him up and he already looked dead. His life has been sucked out of him by the disease. It is certainly hard to see and even difficult to comprehend. The guy probably has less than 6 months to live but could last longer so the torture will continue. Do you want to go for a smoke break?

ENT Clinic Day

Today started at 5:30 am and I just got home at 8:30 pm. I have to be back at the hospital tomorrow morning by 5:30 am for surgery which means I will leave home at 4:00 am. This is that lifestyle I was talking about. If I am on call tomorrow then I will have to stay at the hospital overnight and essentially work a 36 hour shift.

Today was a clinic day I worked with a 2nd year resident and a 5th year resident. We saw 90 patients today. I saw 34 patients myself. ENT clinic mostly deals with patients who have had ear problems, neck masses, mouth cancers, sinus problems, vocal cord issues, swallowing problems and nasal problems that can't be resolved by their primary care physician. Thus by the time the patient ends up in the ENT clinic they have a real issue which is often serious. Today I diagnosed and or informed 4 patients that they had cancer. Most of these were mouth cancers which tend to be very aggressive. We had to set these patients up for surgery to remove the cancers. 

I did several nasoscopes today. This involves taking a scope with a camera on it and feeding it through the patient's nose to visualize the sinuses and ultimately the larynx and vocal chords. I like doing procedures. Procedures also pay very well, specialties that do procedures tend to make more money. For example if a patient comes to the doctor with a chief complaint of congestion and the physician diagnosis acute sinusitis and prescribes an antibiotic the reimbursement will be somewhere around $150.00. If the doctor performs a nasoscope procedure on the same patient to rule out other pathology the reimbursement would be around $600.00 and would not take much more time. For the most part ENT surgeons are the doctors who do nasoscope procedures. Nasoscopes are very helpful for finding nasal polyps or cancers and throat nodules / cancers. Also they help diagnosis sinusitis. 

Today we had a 52 year old african american female who had an onset of bilateral ear pain that started 2 months ago. She had visited the ER 6 times and visited 4 different doctors at clinics over the last 4 months complaining of ear pain. Each time her ears were looked at with an otoscope and appeared normal. She had a 2 CT scans that were normal yet the pain continued. The last doctor she visited prescribed her antibiotics as a last ditch effort even though there did not appear to be an infection. 

The patient took the antibiotic drops for 8 days but did not like the way the drops made her ear feel. She said that it made hers ears and face numb and drove her crazy. She discontinued the medication because of these side effects. She noticed that her ear pain had subsided for a couple of days but was coming back. She returned to the doctor who this time referred her to the ENT clinic. I performed a nasoscope procedure and found 2 nodules on her vocal chords. Everything else about the exam was normal. Her tympanic membranes were intact without any inflammation or signs of infection. I showed one of the residents the nodules on the vocal chords. He agreed with my assessment and we scheduled the the surgery to excise and  biopsy the nodules. If the nodules are cancerous then more surgery and treatments will be required. If the nodules are benign then no further surgery or treatment will be needed. This patient is a great example of the kinds of patients that ENT doctors see.

The Surgeon's Lifestyle

What is the problem with a surgeon's lifestyle? The most obvious issue is that as a surgeon you are basically on call 24 hours / day unless you have partners and you share the call responsibilities. Usually the call schedule in groups like these are something like every 3 - 4 days the surgeon is on call and the other days are covered by the other surgeons in the group. These call days can be and often are hellish. Basically the surgeon ends up working 24 hours on those days because he/she will invariably get calls several times through the evening. 

The other issue is that the regular work days are fairly long and dictated by surgeries that always run longer than planned. You can't say, well it is 5:00 pm so I am going home when you are in the middle of a surgery. The average work week for surgeons runs between 60 hours to 80 hours depending on the type of practice. It is generally accepted in the field of surgery that work has to be the number 1 priority in a surgeon's life, not family, not hobbies and not religious commitments. Not all surgeons are this extreme but even the more mild surgeons are definitely more tied to their work than say a teacher, salesman or an engineer.

In all fields of medicine many hours are often required but for some reason surgery is notorious for the long hours and lifetime commitment. This is one of the major drawbacks to being a surgeon. These are some of the things I have to take into account as I try to decide what area of medicine I want to go into.

Death Of a Generation

On ENT service you see a lot of head and neck cancer. These are usually very aggressive cancers that progress rapidly and kill. These cancers also like to kill young people. Today I rounded on 6 patients all under the age of 40 with death at their door. Each of these patients have throat / mouth cancers and will die in the next year or so. They will have a variety of surgeries to try to put off the inevitable. 

Why do people get these cancers? Nearly 100% of the time these are caused by smoking and or drinking. The combo is a deadly duo. I wish I could video tape my interactions with these patients and show the misery that is cancer and death. Today we had to do a tracheotomy in a 34 year old male with tongue cancer so that we could hook up to a breathing device and prepare him for surgery next week where we will remove a large section of his mandible and tongue. I am sure when this guy took his first smoke at the age of 15 he did not see this in his future. It is interesting to see the staff interact and they say things like "he should not have smoked" and then seem to feel better about it. However the guy is still going to die and it is still unfortunate and regardless of the perceived reasons for the disease someone is still going to lose their dad, brother, best friend etc. I do not find any comfort in thinking the patient brought this upon them self. It still sucks. We all do unhealthy things. 

One thing I have noticed is that it is human nature to want an explanation for a disease or terrible circumstance. It helps us sleep better to know the patient is going to die because of x, y or z. In some way it distance us from the disease and makes us think it won't happen to us because we do not do x, y or z. 

I like ENT, I like surgery which puts me in a predicament because the surgery lifestyle is definitely a time consuming, busy lifestyle which tends to not leave a lot of time for other things. I will continue to learn and search and see if there is a way to be a surgeon and still have a life. There is nothing like walking into the OR scrubbed in and sterile and ready to operate. The rush, the feeling and the adrenalin do not seem to get old. Even the older surgeons still have that look and feel as they come in to operate and I think that is what keeps them coming back. 

12 hours of Surgery

Today was unbelievable. I left home at about 4:30 am and got to the hospital at 6:00 am. I got there a little early so that I could prepare / study for the scheduled surgery. I brought my anatomy book and reviewed all of the anatomy of the neck. It is much easier now to review the anatomy because I have had to study / memorize it for many previous tests. Like anything else it starts to become second nature after a while. 

I reported to OR 10 to get ready for the surgery. Here is some back ground information on the surgery. We removed a Paraganglioma. This is a rare tumor that usually presents in the abdomen, thorax and only 3% of the time in the head / neck. In some rare cases the tumor actually secretes neurosecretory granules like epinephrine and norfiepinepherine which are substances your body normally releases in fight or flight responses. For example the surge of adrenaline you feel when you are scared or angry results for the release of these substances. Your body responds with an increase in heart rate and by sweating, and a myriad of other responses that help you better handle certain situations. This is maintained by your autonomic nervous system. The problem with secreting paragangliomas is that there release extra neurosecretory granules at random times under no modulation. The patient will just be relaxing and all of the sudden breakout in sweat and have a racing heart rate. These random sympathetic nervous responses are the symptoms that usually bring the patient into the doctors office. 

The surgery took 12 hours total with no breaks. We were scrubbed in and working the entire time. Most of the surgery is spent dissecting the neck to get to the tumor which was posterior to the carotid artery. The tumor was golfball size and had its own blood supply and had enveloped much of the normal anatomy. There were many nerves and vessels that we had to be care to not damage. The work is very detailed and meticulous. 

The chief resident and attending physician were both very nice and let me do quite a bit. I went into the surgery knowing that there was a possibility that I would only be allowed to watch. However I was allowed to work the retractors, suture and even do some of the cutting. I certainly got to help out and felt like a member of the team. Of course they were coaching and on guard for any mistakes. It was such a rush to be doing surgery. Particularly such a rare surgery. Most ENT surgeons will only see a couple of these there whole career. Some have never had the opportunity to perform this particular surgery. 

The body is so amazing. The surgery went well and we were able to get the entire tumor out. The chief resident and I went to talk with the family following the surgery. That was cool and I was allowed to explain to the family how it went. The family was so grateful and kept saying thank you. It felt great to be able to help and see the impact of the work. I left the hospital at 7:00 pm on a total high. I had completely forgotten that I had not eat or gone to the bathroom all day. I guess that my own neurosecretory granules / neurotransmitters  kept me going all day. 

Ear Nose & Throat

So far I love surgery. I am on ENT for the next couple of weeks and I have to say that ENT is killer. I grew up across the yard from one of the most world renown ENT surgeons and I tormented his family on a regular basis as a child. I mentioned his name to several of the attending physicians and the residents and they were all very interested to know that I had scratched His daughter's cornea with sand, and blew up his mailbox and shot out his window with a BB gun (accident). 

What is so cool about ENT? Well, it is a surgery subspecialty and you work on illnesses (lots of cancers) in the head, neck, ears, mouth and throat. You get to do lots of surgery and manage patients. Also many do cosmetic facial surgery as well; eye lifts, nose jobs, etc. The money is bountiful and the lifestyle is great!

Today we had ENT clinic in the morning and surgery in the afternoon / evening. I saw lots of cool cases. My first 2 patients were out last night having dinner and on the way back to their car they were jumped and smashed in the face by some thugs and robbed. They were hit by bricks in the face. One of them had an orbital blow out. Basically the bone that makes up the eye socket was fractured. The problem with this is that the eyeball and muscle / tissue leak out the hole in the socket into the brain and can cause lots of problems and become entrapped leading to blindness and paralysis of the eye. It has to be repaired with a titanium plate. The surgery is very fascinating and can be done without making incisions by maneuvering around the eyeball. The other gentleman had his mandible fractured by the brick and he will have to have surgery + plus his jaw wired shut. I felt bad for him, he is defending his PhD dissertation in a few weeks and will have his jaw wired shut. 

Nearly every case I saw today had interesting pathology involved. Then this afternoon I was the first assistant on surgery of a lady where we removed huge keloid out of a ladies ear. It was such a cool surgery. It was so exhilarating and I could see doing surgery but the jury is not out on yet on life style. It certainly is interesting. 

Tomorrow I have cancer clinic and Friday I have surgery all day and there are a couple very interesting cases on the schedule. One of the cases is the removal of a paraganglioma that is infiltrating the carotid artery. This is a rare surgery. I will explain what a paraganglioma is in a another blog. I will report on it.

Day before surgery

Tomorrow is the big start of surgery. If you get a chance you can listen to Metallica's song Enter the Sandman. I have been learning this on my guitar and the beginning of the song builds like many of Metallica's songs. I feel like this building rush as I get ready for surgery to start. 

Here is some info about the Surgery rotation at Cook County. There are 5 different specialty surgery rotations at Cook. Each are 2 weeks long so I will get to do 4 of them. The required rotations are Colorectal surgery, Surgical-Oncology, Pediatric surgery. Cardiothoracic and Vascular surgery are elective but I will only get to do one of them. 

The call schedule is q7 which is nice. That means I will only be on call once every 7 days. The other thing I have to stay up on is preparing for the Surgery shelf exam at the end of the rotation. I have already started reading and doing practice questions. I need to do about 2 - 4 hours / day of studying to make sure that I am ready for the test. Supposedly the exam is fairly difficulty. I started reading on friday and I have done about 50 practice questions already.