Done with Surgery

Many students, physicians, and professors say that the most difficult rotation during medical school. The reasons for this statement is because of the long hours and malignant people you have to work with while on surgery. The rotation is particularly difficult for students who have no interest in surgery. 

I did not find the rotation too difficult. I am interested in surgery and I was able to avoid a lot of the difficult personalities by doing ENT and Ophthalmology for part of my rotation. It is well known that the specialties in surgery that do not require general surgery training a different kind of surgeon. 

I feel like I learned a ton on the rotation and I was able to participate in some great surgeries.I have my national board exam on Friday 10/24 (today). I have been studying during any free time I could get during the past 2 months. Hopefully it will be enough to do well on the exam. 

Next, I start internal medicine on Monday. 

Ophthalmology

It has been a while as I have been working long, long hours on ophthalmology. I find it fairly interesting but I do not think that I would like to spend my entire life in the limited field of ophthalmology. Let me explain. Basically we do clinic hours all day long from 8:00 am to 8:00 pm on wednesdays we do minor procedures in the afternoon. These include minor surgeries on or around the eyes like mole removals and eye lifts (cosmetic and out of medical necessity). Also we do removal of different lesions on the eyeball itself. On Fridays we do surgery in the afternoon evenings. These include retina, corneal surgeries, cataract removal, and other complex eye surgeries. 

Basically ophthalmology has a narrow scope of pathology and the patients also fit into a narrow category. By the time a patient comes to see an ophthalmologist besides basic check ups they have serious disease. These are patients with glaucoma, end stage diabetes macular degeneration, and on the milder side cataracts. For more serious procedures a corneal or retinal specialist is required which is additional training beyond general ophthalmology and limits the practice even further. Also the training in ophthalmology is not very applicable to day to living. If someone goes down on a plane or in public an ophthalmologist would not be the best equipped to handle the situation unless it involved trauma to the eye and even then many  other fields are also trained in managing trauma to the eye. Another issue that ophthalmology is facing is the turf war that optometry has been fighting. Optometrists are lobbying and trying to encroach on the practice of ophthalmology. Often the public is unaware of the differences which adds to the issue. Obviously there are many areas of ophthalmology that optometrists will never be able to touch due to the fact that they did not go to medical school and they can't do surgery.

What do I like about ophthalmology and why is it a competitive field? Well it is all about pay and lifestyle. A practicing ophthalmologist has very light hours and rarely emergency calls in the evening. Also they make decent money but this has been declining over the past several years. Ophthalmologists were one of the highest paid specialties in the 80's and early 90's but the reimbursement has dropped significantly where today they do well and better than average but they are certainly not one of the higher paid specialties anymore. Another good thing about ophthalmology is that it is procedure based and there is some surgery involved in their work. Also they get to sit during surgery which is nice. The surgeries are obviously confined to the eyes. 

I like doing this rotation and it has been interesting to learn and see what ophthalmologist do. I have become proficient at doing eye exams, glaucoma screening, dilating eyes and using the slit lamp to examine eyes. It is actually not that difficult once you get the hang of it and it is not to complicated to see the pathology that affects the eye. You are looking at a very small area and so any disease sticks out well. You look at the blood vessels in the back of the eye, the lens, the cornea, retina, optic disc, optic nerve. I have also done a few ultrasounds on eyeballs to detect retina detachment. 

Men can get breast cancer too!

Today I had 2 cases in the OR and then an afternoon of surgical oncology clinic. We had a rare case of male breast cancer and performed a mastectomy today to remove the cancer. This patient is a 30 year old hispanic male who noticed a lump in his right nipple about 2 months ago. He went to his primary care doctor and was told it was most likely nothing given his gender and young age. He noticed that the lump was growing and made an appointment with  a different doctor 1 month later. The 2nd doctor refereed him to the surgical oncology team for evaluation. He had a core needle biopsy and it was sent to pathology to get a diagnosis. The pathology came back as ductal carcinoma. 

How rare is male breast cancer? Men are a 100 times less likely to get breast cancer than females or you could say females are 100 times more likely to get breast cancer than men. However once a man gets breast cancer, the prognosis and outcomes are identical to women. Unfortunately men usually present much later than women and the cancer is further progressed than the average women presenting with breast cancer. Often men will die from their breast cancer due to delayed treatment and metastasis. The average age of a man diagnosed with breast cancer is 65. Men have a higher risk if their mother had breast cancer. 

Today's patient was fortunate that his cancer was diagnoses relatively early. We removed all of the breast tissue and made sure that there was not cancer in the chest wall. We also removed the sentinel axillary lymph node which is the first node that a breast cancer spreads to. His lymph node was negative, if the node was positive then we would have had to take more nodes. He will have a 6 week course of radiation and then regular follow up exams. It looked like we got all the cancer and there was no evidence of metastasis. His mother had breast cancer and I believe his grandmother did as well.

Following the surgery I had the responsibility of talking with his girlfriend and family. As you could imagine they had tons of questions about the cancer. They were still in shock and had trouble believing that he had breast cancer. I reassured them that the surgery went well and that it looked like we got all the cancer. I also explained how the remainder of his treatment would proceed. The treatment protocols are the same for men and women except that you always do a mastectomy in men rather than breast sparing lumpectomy because they do not have enough breast tissue and like women with small breast it makes more sense to do the mastectomy. Obviously a man does not have the social stigma with a missing breast that a woman would have. 

This was an interesting case and fairly rare, so I was glad that I was able to help with the surgery. 

The surgical ego

After a month and 1/2 in surgery I have developed some interesting thoughts regarding the specialty. Do you know the difference between God and a surgeon? God does not think he is a surgeon. It is amazing how so many surgeons are megalomaniacs. The specialty has many malignant individuals. I am generalizing and there are plenty of exceptions to the rule and humble nice surgeons. Many of the surgeons I have been working with are rude, condescending and basically treat those around them like trash. 

I think there is a certain personality that is attracted to surgery but they are not as malignant when they start. I think that the long hours and the berating they take from their mentor surgeons transforms them into the ego filled physicians they become. Most surgeons I talk to have told me "if you can see yourself doing anything other than surgery, then do it!" Many are not happy with their lives. The hours are long leaving no time for other things and the reimbursement has significantly decreased. 

The surgical subspecialties like ENT and Urology attract a totally different surgeon and seem to have a much better lifestyle. I could see the difference when I worked with ENT. There was no yelling in the OR and the hours were better. Everyone had a life outside of work. 

I like surgery but I am not sure if all the added headaches and malignant people are worth making a career out of it. I am still on the fence.

The disappearing cancer

Today was a long day in the OR but once again I loved it. (4:30 am to 8:30 pm) Today's patient was a 54 year old hispanic male with a chief complaint of weight loss, vomiting, epigastric pain, and anorexia. Whenever a patient like this presents the first thing we think of is cancer. So he was worked up with endoscopy and imaging studies. The CT showed a suspicious mass near the pyloric sphincter in the stomach. The mass was visualized with endoscopy and a biopsy was taken from the mass and sent to pathology. H. pylori levels and gastrin levels were measures. H. pylori is a bacteria that can set up shop in the stomach and cause ulcers and lead to cancer. If a patient has high gastrin levels it is a marker for a tumor related to Zollinger-Ellison syndrome which causes hyper secretion of gastrin = too much acid = breakdown of the stomach.

The results of all the tests were as follows; gastrin levels were normal, H.pylori was +, the biopsy of the mass showed it to be cancer. So we had a diagnosis of gastric cancer. The patient was immediately put on triple therapy for the H. pylori and scheduled for surgery. This all took place about 1 week ago and today was his day for surgery. 

Gastric cancer occurs at a rate of 10/100,000 in the USA but at a rate of 80/100,000 in Japan. Japan has always had a high rate of stomach cancers. This is due to there high levels of nitrates in their foods. Smoked fish and other preserved foods have been shown to cause gastric cancer along with smoking & alcohol. Japan leads the world in gastric cancer therapy and they are very aggressive in screening and treating gastric cancer. Gastric cancer is fairly aggressive. In the USA you have a 25 - 50% chance of surviving 5 years if diagnosed with gastric cancer. In Japan you have more than 50% chance of surviving. This is mostly due to their early detecting and aggressive treatments. In the USA patients are not diagnosed until the cancer is too far progressed. 

We went to the OR to remove the patients stomach. The treatment for gastric cancer involves removal of most of the stomach to all of the stomach (complete gastrectomy). We were plaining a partial gastrectomy as the tumor was relatively small and the cancer was in the early stages. The residents and I scrubbed in and began the surgery. We cut through the different layers to ultimately expose the stomach. We had to tie off many vessels in preparation for the removal of the stomach. As we exposed the stomach we looked for the cancer, but to our surprise we could not find it. We figured that it has to be there and that when the attending physician arrived he would point it out to us. We did find 2 enlarged lymph nodes. We continued to prep the stomach when the attending arrived. He scrubbed in and we informed hi that we could not find the tumor. He had reviewed all the images and lab reports and immediately went to the location of where the tumor was supposed to be. He began to laugh and asked if we were playing a joke. He said "this is not the right patient! I do not see any cancer." We actually double checked the patient to make sure it was the right guy even though we had checked all the protocols before the surgery. Sure enough it was the right patient.

We called for the endoscope to look around the inside of the stomach. We had exposed the external portion of the stomach but we needed the endoscope to see the inside of the stomach. We were sure once we were in the stomach we would see the cancer, after all we had a positive biopsy from 1 week ago. We looked all over the inside of the stomach with the camera and could not find anything. It was a perfectly healthy stomach. We could not see any area that remotely resembled a cancer or even an ulcer. This was very mysterious. We spent a few hours going over the inside and outside of the stomach looking for any signs of a tumor. We biopsied the 2 swollen lymph nodes coming off the stomach and sent them to pathology. The attending thought that the lymph nodes looked very suspicious for cancer. However when the labs came back it showed that the lymph nodes were negative for cancer. We were all surprised by this and after much discussion and several different doctors being consulted to look at the case in the OR the attending announced that there was no cancer and that we could close without performing a gastrectomy. 

It was the patients lucky day as there was no cancer and he kept his stomach. Gastrectomy patients do not do very well and have a high risk of mortality. The attending explained that he had only seen this once before but had read several Japanese studies about this disappearing gastric cancer. The Japanese had reported for years that if a patient is diagnosed with gastric cancer in the very early stages and positive for H. pylori as many are they could be treated for eradication of the H. pylori and in some cases the cancer actually disappears. THe treatment involves antibiotics and a proton pump inhibitor (like prilosec). Most USA surgeons do not believe these reports as the Japanese have had difficulty showing this in the lab and only had in vivo cases reported. We were all believers now. We even had the pathologist come down and see  that that cancer was no longer there. 

The photo was taken while we were doing the endoscopy. The bulging structure is the stomach. We pumped it full of air so that it would remain open for easier viewing with the camera. The structure lying above it that is not bulging is the liver. 

We closed up the patient and could not wait to tell him and his family the good news. Sometimes there are happy endings and it is nice to have one once in a while. It was a good day!