Snow = no test

After all the stressing and cramming for my exam on last friday it turned out that we had a huge snowstorm and the exam was cancelled. Some of my classmates were bummed because this means that they have to study over the break and can't quite relax as well. I am fine with it. It just means I have more time to prepare. These exams cover so much material that there is no way you could ever be fully prepared. It has been said that even physicians who have been practicing for years will still miss a handful of the questions on these national shelf exams. 

Now I have 2 weeks to relax and enjoy the holidays and do some studying. The exam will be scheduled sometime in the beginning of January. I start pediatrics on January 5th. I will be on that rotation for 6 weeks. I am not super excited about dealing with the crazy parents demanding antibiotics and other treatments that they saw on TV or heard about from a neighbor. The thing that can be difficult about kids in suburban populations is that the parents are so emotionally involved that it can be difficult to have a rational conversation with some of them. However my rotation is going to be in the city and will be inpatient so I will be dealing with a poorer population with some really sick kids. This should be very educational. I have heard that it is a good rotation. I am not sure how much if any, outpatient clinic there will be on this rotation. 

Internal Medicine Exam

My last day of Internal Medicine was Wednesday and since then I have been studying for my shelf exam which is tomorrow. This is the exam that every medical student in the country takes after their internal medicine rotation. I think that the national mean is a 74%. In order to get an A in the rotation you need to beat the national mean by 0.25 standard deviation above the mean. In addition to getting above the mean you also have to get an A on your clinical rotation. The clinical grade comes from ratings from the doctors you work with during the rotation.  We shall see how it goes. So far I have been able to beat the mean on the exams from my previous rotations. Hopefully I can keep that trend going. 

I start pediatrics in January.

All Star Wrestling

Last night I was on call and the craziest thing happened. I got a call from an attending physician in the community and he said that one of his patients with a history of cardiac problems was being admitted for an unexplained hemoglobin. He asked my team to take care of the patient. The patient was a 79 year old male that had a history of 2 open heart surgeries (CABG = bypass). He also had a polyp removed from his colon in 2003. Whenever any male over the age of 60 has a declining hemoglobin we worry about an internal bleed. The bleed usually is coming from the colon and often it turns out to be colon cancer. 

The patient's entire family (1 son, 4 daughters and his wife) were all there. It was like a family reunion. It was way past visiting hours but no one mentioned that to the family. I came into introduce myself and examine the patient at about 10:30 pm. It was like a hornets nest with all the family asking me questions like; what is wrong with our dad? are you going to run this test or that test? why aren't you doing this or that? Everyone has suddenly become an expert and wants to question everything. I spent extra time explaining everything to the family. Once you get beyond the surface level of knowledge the family members quickly became lost and realized we knew what we were doing. 

As I was examining the patient and explaining things to the family I realized that the patient that was sharing the room on the other side of the curtain was becoming agitated. He was not my patient. He looked like he was in his mid thirties and had a rough go at life. I looked like he may be detoxing. As the examination went on he became more distressed and finally while I was listening to my patients heart I was jumped on and punched by the neighboring patient. He had stood up on his bed and lunged / jumped through the curtain and on to me. He was on the other side of the curtain so I did not see this coming. He knocked me onto my patient and I quickly stood up and turned around to see what was going on. The neighboring patient was yelling and swearing and saying he was going to kill me. He was obviously hallucinating and in the middle of severe alcohol withdraw. I tried to calm the patient down and signaled a nurse to get security. My patient's son wanted to fight the alcoholic patient and I had to convince him to back down. The daughter's and wife were hysterical and 2 of them were crying while my patient was yelling at them to calm down. 

I had the nurse call to try and reach the patient's attending who is infamous for not returning pages and not being available. Security arrived and began to wrestle with the patient and try to restrain him. The patient was tough and put up quite a fight. In the mean time the attending never called back and the nurses were panicking because they needed to sedate the patient but without doctor's orders they were not allowed to administer any medications. This wrestling match had been going on for over 30 minutes. We moved my patient and his family to a different room. The nurses came up to me and asked if I would order a medication for sedation for this alcoholic patient. Given the circumstances I said I would help out and I ordered some ativan and the nurses were able to sedate the patient. Before putting the order in I ran it by my senior just to cover all the bases and she was fine with it and thought I made a good choice. 

I finished up with my patient by doing a rectal and finding blood in the rectal vault and then transfusing 2 units of blood as his hemoglobin was dangerously low. I went to my call room and laid down in bed and just started laughing out loud. "What a crazy night!" I said to myself and then realized how happy I was and how much I loved this job. 

Code Blue

"Attention! Attention! Code Blue in the holding area Repeat ......."  I was quietly writing some notes on one of my patients at 2:30 in the afternoon. I had a post prandial urge to snooze and could envision the bed in the call room. It would be so nice to just lay down for 10 minutes but I knew that was not going to happen. I quickly got up and made my way down to the holding room which happened to be only just down the hall from where I was. Given my proximity I was the first "doctor" on the scene. "Oh great! I thought, it is just me, what am I going to do?" Immediately I started recalling all of the life saving procedures that I had been taught and read over about 1000 times. I ran up to the side of the bed where all the nurses had gathered and saw a lifeless shell of a body laying in the bed. It was a 95 year old women with aspiration pneumonia who had stopped breathing and had no pulse. 

The nurses moved out of the way and I yelled for a crash cart. I immediately listened to her chest and could not detect a heart beat and there was no detectable pulse. I check her airway and could find no obstruction. I yelled out for her code status and I was told she was full code which meant full effort resuscitation  was in order. I started doing chest compression and yelled out for an ambu bag. One of the nurses started bagging the patient. At this point all the residents started to descend on the scene, thankfully. I moved out of the way so that they could take over. We usually switch off doing chest compressions to avoid fatigue.

We put a monitor on the patient and confirmed that she was in asystole which is one stop before complete flatline. We kept doing chest compressions and started to push various medications. After 15 minutes of running the code we were able to bring her back. We had to intubate her and have the ventilator breath for her. We stabilized her and transfered her down to the ICU. The patient has no family that claims her, no next of kin, no friends, nothing. It was a sad situation. She never fully regained consciousness and later that afternoon in the ICU she died. 

What a day! This was just one of my patients from the day. There is never a dull moment and you never know what is lurking around the next corner.

Broken Freezer

I was on call all night last night and I had several cool patients admitted to my service. There were 3 guys all between 19 and 25 years old who work for a manual labor pool. They report each day to work and take whatever assignments they get and go work for the day. When I was in high school my parents made me work for a labor pool so I am familiar with the miserable nature of this job. These 3 strangers were chosen to work for a large meat warehouse that had a giant walk in freezer break and had tons of spoiled meat to get rid of, I told you these jobs suck. Maybe this is why I stayed in school but I would never admit this because that would only give my parents the sweet feeling of success and I am not ready to relinquish my angst yet. 

These guys reported to the job and worked all day long hauling out thawed, spoiling carcasses out to a dumpster. They had to mop up the blood and clean the freezer inside and out. Several times during the day they all complained of headaches and fatigue and some nausea but they did not think too much of the symptoms, being young macho men they figured it was nothing and continued to work through the symptoms. They finished their job and collected their pay and left to go cash their checks. My patient, a 19 year old male, made it home and had a near syncopal event and fell to the floor. His mother knew something was wrong and forced him to go to the hospital. He worked his way through the ER with some vague symptoms but was ultimately admitted due to his decreased cognitive function. He was having difficulty remembering things and at one point forgot where he was. He was worked up for the flu and some of the more common culprits and then admitted to my service. 

Once I got my hands on him and spoke with his mother in great detail it was not long before we had tied his onset of symptoms to his work activities in the freezer. I spoke with some of my senior residents and we decided to run a carbon monoxide level on him. A normal city/suburban dwelling non-smoker will have an average carbon monoxide level of 2-3%. A person with a chronic lung disease will have a level of 5-9% or so and a smoker will have a level of 10-15%. An average non-smoker will start having symptoms at 15% and get sick at much higher than that and if exposure continues the person can progress to expiration. My patient's carbon monoxide levels came back at 29%. He was lucky that he did not die.  We had been treating him with oxygen therapy and when we confirmed the carbon monoxide poisoning we put him in the hyperbaric treatment that our facility is fortunate enough to have and his symptoms resolved. 

We figured that the motor that was part of the broken freezer was leaking carbon monoxide into the freezer which was a closed space and the workers were exposed to toxic levels. The funny thing is that our facility is one of the few in the area to have a hyperbaric chamber and the other 2 workers had similar symptoms that had progressed and they each separately went to separate hospitals where it was determined that they had carbon monoxide poisoning. They were transfered to our facility to have the hyperbaric treatment. Today it was like a labor pool party as the 3 reunited and complained about their horrible job. We all had some good laughs when I told them some of my war stories from my days on the labor pool circuit. They did not believe that I had worked at a labor pool but when I started in on some of my experiences they soon realized I was the real deal. You can't make this stuff up. 

The good news is that all 3 patients were cured and discharged for home and should do ok but may have some short term cognitive difficulties with memory etc. They will return to base line and it will be nothing more than a funny story. They were fortunate. I have to go now, my car is running in the garage, I am warming it up so I can take a nap in it.....

New residents and my last 2 weeks

Today I got a whole new group of residents and started my last 2 weeks of my internal medicine rotations. It is really more a week and a half because my last day of rotations is next on Wednesday 12/17 and then I have a day to study and my national shelf exam for internal medicine will be on Friday 12/19. Then I will be off for a couple of weeks before I start pediatrics at a Chicago hospital. 

My senior resident for this next couple of weeks seems to be a little hard core. She is going to be the chief resident next year and has made herself a name amongst the other residents by being rigid. How does this affect me? If we have a slow afternoon or some time available a more relaxed senior resident may say "why don't you call it a day and go home early" and a rigid senior would say "why don't you stay late and write up a report on COPD and present it tomorrow during rounds" This is why students have such variable experiences on their rotations. You could rotate at the same hospital and have 2 different experiences based on who your senior resident is. I have had fairly decent senior residents and great interns up to this point on this rotation. We will have to see how this last couple of weeks go. 

Tonight I have to prepare a presentation  on hypertension and the criteria for diagnosis and treatment. I will give the presentation tomorrow. It should not be too difficult as the subject is not that complex and I have studied and had so many patients that I have treated with hypertension that I should be able to do the presentation without any extra reading. 

What is that in your urine?

I have a patient right now who is an 87 year old man who has a history of prostate cancer for which he had a TURP = transurethral resection of the prostate. He has a bunch of other illnesses as well. He presented to the ER with abdominal pain and suprapubic pain a couple of days ago. I have been working him up to figure out why he has had this abdominal pain. He is extremely sick and probably not going to make it much longer. We did a bunch of imaging studies looking for a small bowel obstruction or diverticulitis or a colon caner, etc. but nothing showed up in any of the studies. 

The other day I put a catheter in hi so that I could monitor his urine output and watch his kidney function. He is incontinent so I figured a catheter would be win win. Yesterday I noticed that his urine was rather clumpy and dark in color and looked like it had something floating in it. I sent the urine out for analysis and order some imaging of his abdomen and pelvis. It turns out the clumpiness in his urine is fecal matter and the imaging showed a rectovessicular fistula had formed. Basically a hole in his rectum and his bladder formed and a connection between the 2 structures formed. He now passes crap from his rectum into his bladder and out his urethra. I have consulted urology to see if they want to fix it or maybe colorectal surgery will fix it. We have to take into consideration his age and condition. If we determine he is hospice which means we think he has less than 6 month left of life the we will not do the procedure and just try to keep him comfortable. What a crappy situation. It was interesting trying to explain this to his adult children and answer their questions; "you mean there is sh*&# coming out of my dad's d%#%?!! 

Seize the Seizing

Tonight I am on call and while I was getting ready to admit a new patient with pneumonia I was reviewing the chart in the nursing station. All of a sudden the nurses began to panic and one of them yelled for a doctor and said that her patient was seizing. I continued to review my chart but soon realized that I was the closest thing to a doctor on the whole floor. The charge nurse realized this as well and said "doctor, you have to run a code!" 

I ran to the room and began to bark out orders and questions like "get me a crash cart", "Tell me what meds she is on", etc. The patient was writhing back and forth and moaning. The nurse said the patient was having a seizure and had a history of seizures. I did not think that this looked like a seizure so I did a sternal rub to see her response to pain and I noticed that she was guarding and trying to avoid the pain. Next I forced her eyes open with my fingers to see if her eyes had rolled back in her head and to see if her pupils where responsive. I immediately saw that her pupils were reactive and they were not rolled back. I quickly determined that this was not a seizure but rather she was malingering (faking). While holding her eyes open I looked her in the eyes and yelled "you are not having a seizure, knock it off". Almost immediately she sat up and quit the writhing and shortly after this she requested to use her cell phone. If she had been having a seizure she would have been postictal and would not have been able to function enough to request to make a phone call. The nurses were impressed and asked me how I knew she was not having a seizure. I explained how seizures work and described the methodology of determining if a patient is having a seizure. 

I returned to admitting my patient and enjoyed the effects of the adrenaline rush. The hospital is never boring.

This is my job?

Today after many  long hours of being on call I was finally finished and getting ready to go home and I realized that I was not in any rush to leave. I actually wanted to stay and keep seeing patients. I have never had a job where the major goal was not to get out and go home and do as little work as possible. It is odd to me that I get the privilege of doing this for my career. I enjoy it like I enjoy any of my other hobbies which is mind boggling as I have always held work and hobbies as 2 very different things.

I was excited to get home and get some sleep and see my kids and wife but it was great to have this feeling of "I love what I do" It makes it so much easier to do your job when you truly love what you do. I just never realized that it was actually a possibility. I was always skeptical of the idea of truly loving what you do for a career. I will see if this feeling continues or if I burn out at some point.  In the mean time, I am excited to go into my next shift.

On Call

Tonight I am on long call. I arrived at the hospital at 6:30 am this morning which requires me to leave home at 5:00 am. I will be on call through 3:00 - 4:00 pm tomorrow. All in all it is a 20 + hour shift. We have on call rooms where we can sleep at the the hospital. However taking care of the patients through the night takes priority over sleeping. When we are on call we get all new patients admitted to our service. We are responsible for anyone who comes into the hospital during the the time that we are on call. This is when we get new patients. 

You never know what you are going to get when you are on call. It could be a seizure, congestive heart failure, stroke, myocardial infarction, pulmonary embolism, COPD, pneumonia, etc. Sometimes you get a patient that has an unknown etiology and you have to try to figure it out. Often the patients will have multiple co-morbidities. When a patient gets admitted to our service my senior resident decides who is going to get the patient. My team is made up of 2 3rd year medical students, 1 4th year medical student, 2 interns and 1 senior resident. We take turns getting new patients. The senior resident will page me when it is my turn and give me a basic description.

For my 1st patient tonight the senior resident page me and when I returned the call she said; "you ready?" "this is a 66 year old male with a chief complaint of left lower extremity swelling who presented to the ER. He is in room 601." That is the info I get and I go from there to work the patient up and figure out what is going on. This patient had tripped and fallen about 2 1/2 weeks ago and noticed that he had some swelling near his groin. There was not much associated pain. He could walk fine. He did not want to mention it to his wife because he had a big hunting trip scheduled and he did not want her to not let him go. He went on the hunting trip which required a lot of driving and a lot of sitting waiting to shoot elk. Upon returning home he noticed that the swelling was still present, but he continued to wait hoping it would go away. He woke up this morning and noticed that the area was warm and the swelling had not resolved so he called his primary care physician who immediately instructed him to go to the hospital.

Even before I went to see this patient I had a basic diagnosis figured out. My basic thought was that the patient had either cellulitis (infection) or a deep vein thrombosis (DVT). Both can be very serious and both can result in death if not managed correctly. Upon seeing the patient I ordered a venous doppler ultrasound to see if a DVT had formed. Sure enough he had a massive DVT that most likely resulted from the fall he had over 2 weeks ago. This basically helped me rule out the cellulitis. I started the patient on lovenox which is an anticoagulant (blood thinner). I also had to adjust his other medications for his chronic conditions which include hypertension, diabetes, hyperlipidemia. Once I got the patient all worked up and "tucked in" I paged his primary care doctor and let him know what was going on. He was glad to hear that I had managed the patient correctly and he did not have anything to add or change. He will be in to see the patient in the morning. This is how it works. 

Update on the pancreas

It has been an interesting week. I have been treating the patient with the pancreatic pathology. It has been great for me because I have been assigned as the lead "doctor" on this case. So I work as the main contact for all the consulting physicians and the primary care doctor,  so they all page me for updates and to see what I have been doing for his condition. He had a procedure on thursday that was very cutting edge and not a common run of the mill surgery. The GI doctor used a scope to perforate the stomach to view the pancreas. Then he proceeded to asses and remove as much necrotic tissue as he could. He also made sure that previous stents that were placed were still functioning. It turned out that they were both clogged. So he drained both of the previous stents and placed 3 new stents. He also place a nasogastropancreatic tube to flush the pancreas with saline and antibiotics through out the upcoming weeks. The patient has a tube coming out of his nose. We will continue to flush the pancreas through this tube.

Unfortunately he could only remove 20% of the necrotic tissue which means there is going to have to be a surgery this week. So surgery will be called in to remove the pancreatic necrotic tissue. The good news is that there was no cancer found and there was some viable pancreatic tissue. The patient was feeling much better following the surgery so there is a small chance that his body could heal the pancreas on its own but the odds are rare given the large amount of necrotic tissue left. Following the procedure his hemoglobin was low which occurs from blood loss, when I noticed this I ordered a unit of blood to be transfused. We transfused him which brought his hemoglobin up.

I spent a lot of time with his family explaining what was going on and letting them know what to expect. They were very grateful and said that I was the only "doctor" that even talked with them and was honest with them. They said everyone else was aloof and very quick and would not stick around to answer questions. With my lower number of patients that I am managing I do have a little more time than their other doctors but I have noticed the general trend is to spend a little time as possible with the patients and try to get out of the room quickly. This leaves the family and the patient scared and in a cloud of confusion. I certainly do not want to give any false sense of hope or doom so I basically explain the full spectrum of possible outcomes in terms that the family can understand. I often have to simplify the terms but it gives the family and patient a sense of what is going on.

We are all feeling more optimistic this week regarding his condition. We were relieved that we could not find any cancer. Maybe the outcome will be better than we expected but he could still take a turn and decompensate quickly, so we are on guard. This case has been great for learning and I have learned a ton through managing this patient. I guess this is why we train in this manner, it is the best way to figure out how to be a doctor. We will see what this week brings.

Medical Formalities

An interesting aspect of the medical education process is all the formalities involved.  Those of you who know me are aware that I have never been one to like "formalities". If the rule says you need to wear a white shirt, I most likely am going to show up in any color but white. I know this is probably immature but I just can't help it. If these formalities are never questioned we would probably still be wearing fur loin cloths. 

Anyways  there are many rules involved in writing up and performing a physical or doing an exam. As a medical student we are required to do everything by the book which is a good idea because it forces us to learn everything the proper way and then later we can modify things to fit our style. I have spent a lot of time this year learning all the finite details in doing a medical presentation. There is an exact format and order to the way we are suppose to examine and then report on a patient. Ultimately this art cannot be mastered without lots of repetition. Like many other things in life it seems to be a daunting task at first, like learning a foreign language or learning how to play an instrument but soon enough you just get it down and without even thinking about it you have finally mastered the process. 

I am finally getting in my groove with all the formalities of doing physical exams, giving presentations, discussing patients with other doctors, etc. The nice thing about these rules / guidelines is that they provide a framework that help you to remember all the things you need to do and you become less likely to miss things in your exam or presentation. This is an aspect of medical education that I did not realize would require such effort. In talking to younger medical students there is no way to explain to them how or what they will need to do. The only way to really get it all down is lots and lots of real practice and interactions with patients which only comes with time and time takes time, you know.

Fragile Life

I had a patient admitted to my service a few days ago that has been weighing on my mind. This has been an interesting and tragic case. This is a 53 year old male who presented last a few months ago with painless jaundice which is very often a sign of pancreatic cancer. However at the time the patient did not have other symptoms and his cancer work up was negative. He was found to have a gallstone which had been pressing on his pancreas which had caused pancreatitis and ultimately shut the pancreas down. As a result of the pancreatitis the patient developed pancreatic insufficiency diabetes and had to be put on pancreatic enzyme replacement therapy. 

He was followed in clinic throughout the fall. However he has not been well enough to return to his high profile executive job or to drive his car. His wife and older children have been supportive and concerned for his health. Then earlier this week while climbing some stairs he experienced shortness of breath and did not feel well. He knew something was not right. His wife brought him to the ER where he was worked up and admitted as my patient. I am in charge of his day to day work up and care, thankfully I have a deep team of support to help me and more importantly watch my management of the patient to make sure that I am not missing anything or doing something incorrectly. I have my Intern, senior resident, teaching attending physician and the patient's primary care doctor all looking over my shoulder. I also consulted GI, surgery and interventional radiology on the case. I kind of work as the main point of contact with the patient and the family and I keep all the physicians on the case informed.

This case has taken everyone by surprise. The patient has no past medical issues and really no risk factors. He does not smoke, drink or use drugs. He is health conscious and was not over weight. He exercised and ate very well. His case is serious and he has been decompensating over the last week. He continues to have pancreatitis and his mental status has declined and other organ systems are starting to become affected. If he continues at this rate he will die within 7 to 10 days. We are trying to figure out what exactly is going on. We know that his pancreas has failed but his other symptoms are atypical. He has a pseudocyst in his pancreas which will need to be either drained or surgically removed. We should have this addressed by tomorrow. This case has been like an episode of House (the tv show). Right now we are stumped.

My main theory now is that he must have pancreatic cancer that has metastasized and the cancer must have been in the very beginning stages and not detectable in August when he was first seen Tomorrow we are going to work him up again for cancer and see if we can find anything. Hopefully it is not cancer but we can find a less ominous illness. If in fact he does have pancreatic cancer his prognosis will be terminal. 

In July this was a healthy successful father, husband and friend and today he is hanging on for his life. There has been a large number of people that this has impacted. HIs children, his wife, friends are all devastated. Everyone is still hopeful but I think the outlook is grim.

Inpatient care and the hospitalist

I am about halfway through my internal medicine rotation which is one of the main required core rotations required for all medical students. I feel like I am getting the hang of how to manage the fairly sick hospitalized patients. There is of course a lot more to learn and master but I feel like I can make sense of what is going on. I am not sure if I would want to have a career as an internal medicine doctor but I like it much more than I thought I would.

Internists usually divide their practice between seeing patients in clinic for routine outpatient issues and then seeing their hospitalized patients in the hospital. Recently many internists have found that the hospital work is not as appealing or as lucrative as outpatient clinic and so many have hired hospitalists to manage their hospitalized patients. A new field is growing in medicine because of this trend. Now there are jobs available as a hospitalist where as an internist you focus only on hospitalized patients. The job consists of seeing hospitalized patients for community internal medicine doctors who no longer want to manage hospitalized patients. 

I have been working as a hospitalists throughout this entire rotation. I am only seeing hospitalized patients who have a community internal medicine doctor as their regular physician. I could actually see doing this as a job. I like the complex cases and there is a great deal of interaction with the patient and their family. It is usually a stressful time for the patient and their family and they are grateful for all the help they can get. So many doctors fail at even elementary forms of communication, that it does not take much to make the family feel comfortable and happy. Simply taking the extra time to explain to them a diagnosis or a test or their given illness brings so much comfort to them that it is rewarding to interact with them and try to help them.

These patients are fairly sick and take quite a bit of intervention to help them recover and in some cases there is no hope for recovery. I find it rewarding to deal with people during these stressful moments. It is easy to connect and have an impact on their lives and often it also has a great impact on my life. Watching someone watch their loved one die is a unique opportunity that one gets as a doctor and much can be learned from these observations. Fortunately in today's world we are often successful and helping the patient return back to health but this is not always the case. This job also makes you ponder your own and your loved ones' mortality. I find myself wondering what it will be like when I die or when one of my close family members die. For some reason i did not think about these things when I was selling mattresses or when I worked at one of my numerous past jobs / careers. Discuss...

Too old to be gay?

2 days ago we were on long call so I was staying overnight at the hospital and getting new patients admitted to my care. I got a call from the ER with a new patient that I would be responsible for, she was an 83 year old woman who had come in via ambulance after experiencing a fall and some mental confusion. She also had hypertensive urgency / emergency  that needed to be controlled. 

The case its self seemed rather boring and before I had even hung up the phone I was pretty sure of my diagnosis. I was pretty sure that she had a Transient Ischemic Attack (TIA) and it turned out that she had a history of TIA's. This is not an interesting story because of the diagnosis or medical mystery. 

I went into the patient's room to introduce myself and perform a complete exam. This is how we handle every new patient. Part of the exam includes a ton of questions that many seasoned doctors do not bother to ask but as a medical student I am required to be very thorough. This lady was adorable. She was feeling fine and had quite the personality. She told me, she was ready to get home and did not know why she even had to stay. SHe had a friend there with her who had witnessed the TIA and was able to answer many of the questions I had regarding the event. Her friend was also in her 80's and was surprised how well she knew the patient's medical history. When I asked the patient about medications or past surgeries, she would often reply with "I do not remember or I do not know" but her friend would fill in all the gaps and tell me exactly what I wanted to know.

During an exam we have a section called a social history. During this portion we ask questions about tobacco use, alcohol use, illicit drugs, sexual behaviors and history. We also ask about living circumstances, marital status, number of children etc. When I go to this section of my exam, I said to the patient "do you have any grand children?" Usually when I ask an elderly person about their grandkids they get a big smile and begin to tell me all about their wonderful grandchildren and their latest adventures. This patient simply replied with "I never had any children so I do not have any grandkids but I do have some nieces and nephews that I spoil." I asked "are you married" she replied "no, I never got married". I asked her is she lived alone and she said no and pointed to her friend and said we have lived together for more than 45 years and she continued to explain how wonderful their life had been and that they have each other and they are both very happy. The patient's friend added more details about the spectacular life they have had together. 

As we continued the exam it became more and more clear to me how connected these 2 ladies were and it also became apparent how much they loved each other. So I finished up my physical exam and before I left the room to go run some labs I looked at the 2 ladies and said "Do you want to know the secret of your happiness and the success of your relationship?" The smiled and said sure tell us why we are so happy. I said with a smile "it is because you never involved a man, they tend to just screw things up" They both turned a little red and laughed and laughed and then the patient said "well, we could of told you that!"

New group of residents and grades

Sunday I was on long call and it was my last day / night with my residents. Today we got a new group who I will be with for the next 4 weeks. It is always interesting and challenging to figure out how he different residents work, what they like and what they hate. They are my boss so until I figure them out it can be a little tense. For example, you may have 1 resident who wants you to write up a patient and present a patient in a specific way and you get used to doing it their way, then another resident may be completely annoyed by this method and get all over your case for the  charting / presenting method that the other resident wants you to do. You have to be flexible and able to adapt to keep both residents happy. I am working with 3 residents and I am sure they want things done in their own special way. Once I figure their individual likes and dislikes I am pretty good and keep everyone happy. 

My main job is to make my residents look good and do their job better. So many medical students are completely clueless with how to go about doing this and furthermore they are annoyed and feel that they are above this task. They are forced to learn the hard way when they get poor reviews despite their good clinical knowledge. It is just like life where it is about keeping those around you happy, whether it is your spouse or your boss or the cop that pulls you over for speeding. If you can keep these people genuinely happy you do well and your life ends up being being happy and you have less problems.

The grades from 3rd year are arguably the most important aspect of getting you a good residency. The grades are based largely upon your evaluations that you get from the residents and attending physicians that you work with. Many med students who do very well (all A's) during their first 2 years of basic science are frustrated with their poor performance during 3rd year. The grading is subjective unlike the objective grading of the first 2 years. I have always been a fan of the subjective grading and tend to do well where you are graded based on how people like you. When you are applying for residency the resident directors realize that they are going to have to deal with you for the next 3 - 6 years and they want someone that is easy to get along with and someone who works hard. Many residency directors have said that they would take a student with stellar 3rd year grades / evaluations and poor to mediocre clinical science grades over someone who has mediocre 3rd year evaluations but straight A's and great grades test scores from their clinical science years. The perfect candidate would excel in both areas but interestingly enough those that do really well the first 2 years do not do as well during their 3rd and 4th years and often a mediocre student in the clinical sciences will excel 3rd and 4th year.

My patient who died

I had a patient on my service who was in her early 70's. She had been living with her family and had been getting progressively more depressed. She felt that she was a huge burden on her family and recently had said that she would be better off dead. She had also been complaining about a diffuse rash that had spread over most of her body that was accompanied with pain. Her family was skeptical of the pain and even the rash at first. The rash was originally hard to see and she had been so depressed that they did not think that the pain was anything to be worried about. 

She presented to the Emergency Room 3 days ago and became my patient. I did a complete work up and ultimately concluded that she had sarcoidosis which is a not so common disease and we do not completely understand what causes it. It usually affects younger people and causes granulomas to grow in various areas on the body. Usually the lungs are affected but the granulomas can form anywhere. Often this condition will grow slowly over time and can ultimately lead to organ failure and death but it can also appear and grow rapidly.

My patient had signs of neurological involvement which would mean that the sarcoid had spread to the brain which would explain her recent depression and atypical behavior. We decided to have her get an MRI today. I was paged this afternoon and told that while she was getting ready for the MRI she began to decompensate and died. I had to go and verify the death and call the time of death. 

I also had to notify the family and to a certain degree they were relieved that at least she had a diagnosis and there was an explanation for her recent behavior. It is difficult to see a loved one deteriorate mentally and the families are always relieved when there is an explanation for the behavior. 

It was an interesting day and a unique case. Every time I have a new case and patient it is like my database of clinical knowledge grows a little. The hands on learning in the hospital is much more effective than just reading about a disease or case. No wonder the training takes so many years, there is so much to learn. 

Medicine Patient

Here is how I would present one of my patients from today.

48 year old hispanic male presents with a history of a recent MVA (motor vehicle accident) resulting in a spinal injury causing quadriplegia. The patient is in respiratory failure and ventilator dependent. The patient also has a sacral decubitus that was being managed with a wound vac at the nursing home. He also suffers. from depression The patient presents with a fever of 40.1 degrees of unknown origin possibly secondary to pneumonia or UTI.

5 days ago the patient began spiking fevers at the nursing home where he lives. The fever was refractory to acetaminophen so he presented to the emergency department. Chest Xray showed evidence of pleural effusion bilaterally, right side > left. Urine was cloudy with occult blood, traces of protein and leukocyte positive. Urine culture showed subclinical pseudomonas aeruginosa susceptible to tobramycin. 

On physical exam the patients lungs had anterior coarse rhonchi bilaterally more prominent on the right side. The sacral decubitus does not appear to be infected and shows granulation tissue and signs of healing. 

Patient was started on imipenum + vancomycin for pneumonia and IV tobramycin for UTI. We will continue to monitor the patient. We have sent for blood and sputum cultures. We are continuing his lexapro for depression and will have wound control look at his sacral decubitus and possible continue the wound vac

This is a very abridged example of a presentation I may give on rounds. This is a patient that I admitted today and I am currently managing. Most likely this patient has a UTI and or pneumonia which is causing the fever. Given his comorbidities this patient will be managed in the hospital until we can get him afebrile and rid him of any infection. He is actually a good example of the type of patients that I have been managing. 

This case is sad because this guy was a normal healthy man in February until he was hit by a drunk driver which left him a quadriplegic. His wife and family have basically abandoned him in a nursing home. He is mentally aware and just trapped in his broken body. He is severely depressed and miserable. He is just waiting to die.

Internal Medicine Patients

I am actually really enjoying my rotation in internal medicine. I like the challenge. It is kind of like the TV show House. I will get a new patient which is admitted to my service that I have complete responsibility for working up. So I have to come up with the diagnosis and the treatment plan. I certainly have a lot of more experienced residents and attending physicians that I can look to for help and they will also check my work to make sure that I am not missing anything. There is a great deal of satisfaction that comes from figuring out the diagnosis and then treating the patient and ultimately seeing the patient become healthy again.

I do not find it very stressful which may be one of the reasons why I like it. Currently I cover 2 - 4 patients at a time. I suppose if I had 10 - 15 patients it could be more hectic / stressful. I get to see a whole variety of patients. I have had MRSA cellulitis patients and patients with atrial fibrillation, pancreatic cancer, pneumonia, heart attacks, etc. Most of the patients are elderly. Some patients die due to their conditions which can be sad. This requires working with the family members of the patients. This can be very interesting because many times the family members are at odds with the situation or not prepared for the decisions that they need to make.

Internal Medicine

So I started internal medicine at a new hospital. The hospital has a much different demographic than the city hospital where I was doing surgery. What is internal medicine? Internal medicine is basically adult medicine. An internist is the doctor that takes care of adults for most health issues. The training is a 3 year residency. I would say that most adults see internists. They differ from family practice doctors in that they do not see children and they tend to see sicker patients. Often internists will manage adult patients that are hospitalized. 

This rotation is 100% inpatient. I do not see any patients in clinic. All of my patients have been admitted into the hospital where I am involved in managing their treatment while they are in the hospital. Most of my patients are fairly sick. I will see patients that are end stage renal failure or have serious pneumonia, or other illnesses requiring hospitalization.

I am on this rotation for 2 months. I just finished my first week and I actually really like it. It is interesting trying to figure out all of the patient's health issues. It is like a mystery and it feels great to figure out what is wrong and then treat the patient and get them well enough to go back home. I have had some really interesting cases thus far. I am on call  every 3 days. I alternate between long call and short call. Long call is overnight, so I come in at 6:00 am and will stay through the day and overnight and then leave the next day at about 1:00 pm. It is a 32 - 34 hour shift. Short call starts at 6:00 am and goes until about 8:00 pm the same day so it is a 14 - 16 hour shift. The hours can be long. 

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!

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.