Today has just been one of those days. You know, one of those days where you come in the morning all studied up and ready to scrub in on a radical cholecystectomy with liver resection and lymph node dissection (and ready to impress, having memorized all the staging systems and appropriate treatments and prognoses for gallbladder carcinoma), but end up getting diverted to a colorectal resection which starts out laparascopically but turns into an exploratory laparotomy (open surgery), and then the anastamosed (reconnected) colon somehow loses its blood supply and starts to die and you have to do it all over again with another piece of colon and now the patient has an ileostomy too and it was supposed to take 3 hours but it took 8... and then the second patient of the day who was supposed to go at 11 ends up going at 6 and has a carcinoma of the pancreas which has decided to wrap itself around the superior mesenteric artery thereby making it unresectable (read: we opened him up and couldn't take the tumor out anyway). And when it's all finally over at 11 PM you just want to shoot yourself so you don't have to come in at 5:30 AM again tomorrow morning.
You know... one of those days.
Saturday, January 5, 2008
Tuesday, November 6, 2007
OB/GYN: Bringing Forth Life
In real life, the uterus looks just like it does in picture books. Springing forth from behind a curtain of fat and abdominal muscles in the depths of an incised abdomen, it's a strange, almost whimsical shape which is easily recognized as "uterus!"-- even by the unseasoned medical student. On the inside, the uterus looks just like a blood-soaked sponge, and it's easy to imagine that if you were just to rinse and wring it out, it might be ready for another go on the kitchen counter.
These were my observations today on my first two C-sections. This operation is easily the most unique of the common operations: whereas it is extremely invasive, the patient is awake-- and very aware of what is happening to her body behind the sterile drape.
It all begins with a nervous mother-to-be seated on the operating table with her bare back to the door. Regardless of how fat or thin she may be, and despite the funny shower cap surgical hat she is wearing, I am struck by how beautiful she looks in her nakedness. This is her monologue under the bright OR lights; she is the quiet center of commotion as the OR staff prepare for the procedure.
The operation will involve up to 20 people, from OR staff to anesthesia to OB/GYN to pediatrics, each a perfect gear turning in time with its colleagues. An anesthetist sterilizes and drapes her back, then injects a spinal block. Her legs go numb, then limp; she loses pain sensation from her abdomen down. She is helped to rest on the operating table and draped: she becomes nothing but a vast blue sterile field with a hole on the abdomen. The freshly scrubbed obstetric team enters, dripping, and is gowned and gloved. The OR nurse hurries to set up her arrays of instruments. Pediatrics people shift impatiently from foot to foot next to the empty, expectant incubator. The stage is set.
From here, the plot thickens and becomes free to veer off wildly in unimaginable directions. She may be hugely pregnant and ready to burst with triplets... or barely showing with a 14 week premie who will tip the scale at scarcely more than a pound and make only faint, exasperated movements of the head and arms. The first incision draws superficial blood, some of it squirting skyward in its great eagerness to get out of her body. The underlying connective tissue is carefully dissected. The rectus muscles are revealed, glistening and taut. They are pulled violently aside by the obstetrician and his assistant to widen the sight line into the peritoneum; a maneuver that requires strength remniscent to me of the Army football team playing tug-of-war with Navy.
The uterus appears through the translucent peritoneum, protecting its precious cargo. Inside the soft muscle is a living soul preparing to enter the world. The rest of the operation is a blur because here the emotions begin to run high. After we enter the uterus, a gush of fluid (here I silently thank my lucky stars for choosing the mask with a face shield) signals rupture of membranes, and suddenly a grey, drowned rat is being pulled free from its mother's abdomen. I stand transfixed, shocked: it's almost like a scene from... what's that movie where the aliens take over human bodies and burst forth from their abdomens? The rat mews weakly. Mouth and nose suctioned. Quickly rubbed dry. Cord clamped and cut. Handed to mom. Tears rolling down her face. Her new child. The pediatrics team swarms in.
Our emotions spent, we turn our attention to undoing the hole we've made in mom's abdomen. And what a hole it is... her uterus hanging outside the skin, the muscles separated like a drawn curtain, blood everywhere. So we clean up our mess with what tools we have: sutures here, electrocautery there, more sutures, staples. What intricate handiwork! When we've finished, the neat incisional scar mocks the havoc we wreaked beneath it. We apply the white dressing, just to make further assurance that its tight lips will never divulge her secret.
I look over at the incubator several minutes later, and see that the rat has turned into a plump, pink infant. I can't help but smile behind my mask; it is only fitting that this first chapter of life makes such a traumatic, exuberant, and eloquent preface to all the rest. Happy birthday, kid.
These were my observations today on my first two C-sections. This operation is easily the most unique of the common operations: whereas it is extremely invasive, the patient is awake-- and very aware of what is happening to her body behind the sterile drape.
It all begins with a nervous mother-to-be seated on the operating table with her bare back to the door. Regardless of how fat or thin she may be, and despite the funny shower cap surgical hat she is wearing, I am struck by how beautiful she looks in her nakedness. This is her monologue under the bright OR lights; she is the quiet center of commotion as the OR staff prepare for the procedure.
The operation will involve up to 20 people, from OR staff to anesthesia to OB/GYN to pediatrics, each a perfect gear turning in time with its colleagues. An anesthetist sterilizes and drapes her back, then injects a spinal block. Her legs go numb, then limp; she loses pain sensation from her abdomen down. She is helped to rest on the operating table and draped: she becomes nothing but a vast blue sterile field with a hole on the abdomen. The freshly scrubbed obstetric team enters, dripping, and is gowned and gloved. The OR nurse hurries to set up her arrays of instruments. Pediatrics people shift impatiently from foot to foot next to the empty, expectant incubator. The stage is set.
From here, the plot thickens and becomes free to veer off wildly in unimaginable directions. She may be hugely pregnant and ready to burst with triplets... or barely showing with a 14 week premie who will tip the scale at scarcely more than a pound and make only faint, exasperated movements of the head and arms. The first incision draws superficial blood, some of it squirting skyward in its great eagerness to get out of her body. The underlying connective tissue is carefully dissected. The rectus muscles are revealed, glistening and taut. They are pulled violently aside by the obstetrician and his assistant to widen the sight line into the peritoneum; a maneuver that requires strength remniscent to me of the Army football team playing tug-of-war with Navy.
The uterus appears through the translucent peritoneum, protecting its precious cargo. Inside the soft muscle is a living soul preparing to enter the world. The rest of the operation is a blur because here the emotions begin to run high. After we enter the uterus, a gush of fluid (here I silently thank my lucky stars for choosing the mask with a face shield) signals rupture of membranes, and suddenly a grey, drowned rat is being pulled free from its mother's abdomen. I stand transfixed, shocked: it's almost like a scene from... what's that movie where the aliens take over human bodies and burst forth from their abdomens? The rat mews weakly. Mouth and nose suctioned. Quickly rubbed dry. Cord clamped and cut. Handed to mom. Tears rolling down her face. Her new child. The pediatrics team swarms in.
Our emotions spent, we turn our attention to undoing the hole we've made in mom's abdomen. And what a hole it is... her uterus hanging outside the skin, the muscles separated like a drawn curtain, blood everywhere. So we clean up our mess with what tools we have: sutures here, electrocautery there, more sutures, staples. What intricate handiwork! When we've finished, the neat incisional scar mocks the havoc we wreaked beneath it. We apply the white dressing, just to make further assurance that its tight lips will never divulge her secret.
I look over at the incubator several minutes later, and see that the rat has turned into a plump, pink infant. I can't help but smile behind my mask; it is only fitting that this first chapter of life makes such a traumatic, exuberant, and eloquent preface to all the rest. Happy birthday, kid.
Saturday, October 20, 2007
Medicine: "And I hate when things are over...there's just so much left undone." -Breakfast at Tiffany's (Deep Blue Something)
Hello my lovelies, long time no see! It's been a while since my last entry, be it a testament of how busy Medicine has kept me or how bad I am at multi-tasking. In any case, it's the day after Medicine is over and time to reflect on the past 8 weeks, so without further ado...
I want for you to share this feeling with me. It's somewhat described by the following metaphor: When we first get these new sneakers, they're unfamiliar and uncomfortable, needing some breaking in. But since they're still shiny and novel, we're excited to wear them anyway. We wear them in for a while, finding moments that they're hard to keep on. In time, we discover the magic (aka sticking power) of velcro and apply them to our sneakers. There! Much easier but somewhat awkward-looking. So we continue to look for a better way to keep these sneakers on. Eventually, we learn how to tie the shoe laces and no longer need the velcro. Now we're really walking confidently and effortlessly (relatively speaking...). For a while that's what we do, until the end when someome tells us too soon that it's time to get a new pair. As fun as that sounds, we're now comfortable...and perhaps attached...but we reluctantly give these up, and ready ourselves for the next pair.
If the above made absolutely no sense, all I'm trying to say is that I'm going to miss Medicine.
...to be continued...
I want for you to share this feeling with me. It's somewhat described by the following metaphor: When we first get these new sneakers, they're unfamiliar and uncomfortable, needing some breaking in. But since they're still shiny and novel, we're excited to wear them anyway. We wear them in for a while, finding moments that they're hard to keep on. In time, we discover the magic (aka sticking power) of velcro and apply them to our sneakers. There! Much easier but somewhat awkward-looking. So we continue to look for a better way to keep these sneakers on. Eventually, we learn how to tie the shoe laces and no longer need the velcro. Now we're really walking confidently and effortlessly (relatively speaking...). For a while that's what we do, until the end when someome tells us too soon that it's time to get a new pair. As fun as that sounds, we're now comfortable...and perhaps attached...but we reluctantly give these up, and ready ourselves for the next pair.
If the above made absolutely no sense, all I'm trying to say is that I'm going to miss Medicine.
...to be continued...
Saturday, September 15, 2007
Medicine: R/O Radiology
Today, I went down to Radiology to get a preliminary reading of a CT on a patient. I had never been to where the radiologists work before. I've heard all sorts of jokes about how if you're afraid of the dark you should go into ophthalmology, and if you're afraid of the light you should go into radiology, but I've never seen what it's like firsthand. Now I know that I never want to go there again. The radiologists sit in the dark (and I'm not even kidding in the slightest here) in a large, labrynthine room of cubicles, each with 2 huge flat screen computer displays. They stare at the computer screens in the dark. All day. I can officially say that within the first 30 seconds, radiology was ruled out as a career for me-- if I wanted to spend the rest of my life sitting in a dark cubicle staring at a computer screen, I could have skipped the 4 wasted years of youth in med school and $150K of debt, and started off at twice the salary I'm going to make as an resident using my Bachelor's degree as a computer programmer.
Radiology? An emphatic noooooo, thank you.
Radiology? An emphatic noooooo, thank you.
Monday, September 10, 2007
Medicine: My First Brush with Cancer
I am proud to announce that in the last 2 weeks, I have figured out how to get from South Building to 4-West, not just what a sign-out is but also how to do it, and settled neatly into my spot at the bottom of the medical totem pole. I still do the 180 outside every elevator, though. I don't think I'll ever be able to kick that ritual. I followed my very own patient from a quivering wreck on Dilaudid in the ER through to happy, ambulating discharge 4 days later, and although everyone else on my team got a handshake, I was the only one who got a hug (I'm unabashedly proud of that-- and it was a big, badass guy, not a touchy-feely little old lady). I feel integrated. I feel like I am actually making a difference.
Midway into week 2, I was asked to "look up" rare coinfections with Lyme disease (namely, Babesiosis and Ehrlichiosis for those who care for such pedantry). Ehrlichiosis presents with fevers, myalgias, thrombocytopenia (low platelets), and elevated liver enzymes. I don't believe I will ever forget the symptom complex for Ehrlichiosis, because a patient came in that very morning with a symptom complex and history of present illness so definitive for Ehrlichiosis that we might as well have watched the tick bite him. He was our Ehrlichiosis patient. Or was he?
We began the standard treatment regimen with doxycycline and sent his blood out for serology at a lab in Utah-- the only lab in the country that performs the blood test for Ehrlichiosis. His fevers and joint pains went away, and then returned with a vengeance. Despite the appropriate treatment, his blood labs continued inexorably on their negative course. He was in pain, a pathetic body on the bed, sweating and asking us daily why we couldn't do anything. We increased his pain medication. We gave him laxatives. We increased his pain medication some more. We waited for the serology to return, to confirm the diagnosis we were so sure was true.
Our patient's condition continued to worsen. Confidence in our diagnosis waned to hope against hope, because by this time, we had widened our differential diagnosis and set up plan B: if our serology for Ehrlichiosis came back negative, we would have to start thinking cancer. We would go where the money is and biopsy the bone marrow. Our patient had stopped looking like the classic case of Ehrlichiosis and started looking just like an atypical presentation for leukemia or lymphoma-- and we had ruled out almost everything else.
One morning, his daily blood count came back with "atypical lymphocytes" on the smear (under the microscope). A marrow biopsy was performed the very next day. As we began preparations for transfer to the Hematology-Oncology service, our Ehrlichiosis serology fell by the wayside, forgotten. I don't even know what the results are, if they ever came back; I assume they were negative, but it really didn't matter anymore.
It was almost a blur how quickly he was gone from our service, whisked up by Oncology into a world of immediate chemotherapy, considerations for bone marrow transplantation, and months of suspense about whether he would live or die. I would have imagined that a patient diagnosed with cancer would need weeks to come to terms with the diagnosis before he could begin to undergo chemotherapy. In reality, things move at a breakneck pace; there was barely time to turn around, blow a kiss, and wave before this huge change took over his life. But time is a mysterious beast; inside my patient's mind, life may have turned to slow motion. I don't know.
I think I learned 2 important lessons from this patient's case. The first is a principle I was taught in the abstract last year: YCMTDIYDTOI. What the heck does YCMTDIYDTOI mean, you ask? Well, its name illustrates its principle: You Can't Make The Diagnosis If You Don't Think Of It (and you certainly can't figure out what this acronym stands for if you don't already know it-- and think of it). The best clinicians have been said to use pattern recognition, but sometimes patterns are not the be all and end all of diagnostics. Solving problems in the real world is totally different from solving textbook cases in my first and second year lectures, where anyone who had pneumonia came in with a cough, a fever, and a dullness to percussion over the right lower lobe. You have to start somewhere-- but from there, you must grow.
The second, and more important, lesson I learned from this patient is that cancer is never expected. Nobody comes into the hospital thinking "I must have cancer." It is sobering to know that at any point, any one of us could walk in with a fever and some aches, and walk out with a diagnosis that might change our lives. The line between health and illness is finer than I had ever appreciated, and every step we take on the side of health should be a thankful one. When we do cross that line, we won't know how far we've gone-- whether we'll be cured in a week with antibiotics, or whether life will start being measured in probabilities of survival months. The journey is seldom in black and white, and it is always frightening and confusing. It's a good lesson for me to have learned now, because I will spend the rest of my life escorting my patients along that road.
Midway into week 2, I was asked to "look up" rare coinfections with Lyme disease (namely, Babesiosis and Ehrlichiosis for those who care for such pedantry). Ehrlichiosis presents with fevers, myalgias, thrombocytopenia (low platelets), and elevated liver enzymes. I don't believe I will ever forget the symptom complex for Ehrlichiosis, because a patient came in that very morning with a symptom complex and history of present illness so definitive for Ehrlichiosis that we might as well have watched the tick bite him. He was our Ehrlichiosis patient. Or was he?
We began the standard treatment regimen with doxycycline and sent his blood out for serology at a lab in Utah-- the only lab in the country that performs the blood test for Ehrlichiosis. His fevers and joint pains went away, and then returned with a vengeance. Despite the appropriate treatment, his blood labs continued inexorably on their negative course. He was in pain, a pathetic body on the bed, sweating and asking us daily why we couldn't do anything. We increased his pain medication. We gave him laxatives. We increased his pain medication some more. We waited for the serology to return, to confirm the diagnosis we were so sure was true.
Our patient's condition continued to worsen. Confidence in our diagnosis waned to hope against hope, because by this time, we had widened our differential diagnosis and set up plan B: if our serology for Ehrlichiosis came back negative, we would have to start thinking cancer. We would go where the money is and biopsy the bone marrow. Our patient had stopped looking like the classic case of Ehrlichiosis and started looking just like an atypical presentation for leukemia or lymphoma-- and we had ruled out almost everything else.
One morning, his daily blood count came back with "atypical lymphocytes" on the smear (under the microscope). A marrow biopsy was performed the very next day. As we began preparations for transfer to the Hematology-Oncology service, our Ehrlichiosis serology fell by the wayside, forgotten. I don't even know what the results are, if they ever came back; I assume they were negative, but it really didn't matter anymore.
It was almost a blur how quickly he was gone from our service, whisked up by Oncology into a world of immediate chemotherapy, considerations for bone marrow transplantation, and months of suspense about whether he would live or die. I would have imagined that a patient diagnosed with cancer would need weeks to come to terms with the diagnosis before he could begin to undergo chemotherapy. In reality, things move at a breakneck pace; there was barely time to turn around, blow a kiss, and wave before this huge change took over his life. But time is a mysterious beast; inside my patient's mind, life may have turned to slow motion. I don't know.
I think I learned 2 important lessons from this patient's case. The first is a principle I was taught in the abstract last year: YCMTDIYDTOI. What the heck does YCMTDIYDTOI mean, you ask? Well, its name illustrates its principle: You Can't Make The Diagnosis If You Don't Think Of It (and you certainly can't figure out what this acronym stands for if you don't already know it-- and think of it). The best clinicians have been said to use pattern recognition, but sometimes patterns are not the be all and end all of diagnostics. Solving problems in the real world is totally different from solving textbook cases in my first and second year lectures, where anyone who had pneumonia came in with a cough, a fever, and a dullness to percussion over the right lower lobe. You have to start somewhere-- but from there, you must grow.
The second, and more important, lesson I learned from this patient is that cancer is never expected. Nobody comes into the hospital thinking "I must have cancer." It is sobering to know that at any point, any one of us could walk in with a fever and some aches, and walk out with a diagnosis that might change our lives. The line between health and illness is finer than I had ever appreciated, and every step we take on the side of health should be a thankful one. When we do cross that line, we won't know how far we've gone-- whether we'll be cured in a week with antibiotics, or whether life will start being measured in probabilities of survival months. The journey is seldom in black and white, and it is always frightening and confusing. It's a good lesson for me to have learned now, because I will spend the rest of my life escorting my patients along that road.
Tuesday, August 28, 2007
Medicine: Overwhelmed
I think the dictionary should be revised. Next to "overwhelming," the definition should be changed to read, "a third year med student's first day in the hospital."
I can't say I've been in very many hospitals, so I don't have any basis for comparison... but I'm pretty sure they imported the Labyrinth straight from Greece, put some hospital beds in it, and called it Hospital. I'm convinced that any one of these days, I'm going to make a wrong turn going from South Building to 4-West and run into the Minotaur himself. My greatest daily embarassment (actually, come to think of it, a ritual) is getting out of the elevators in the morning, walking purposefully forwards, realizing I'm going in the wrong direction, and making an abrupt 180. I think the fact that I'm wearing a white coat (and thus look like I actually know what I'm doing) makes it only more comical. I hope it will get better.
But the overwhelmingness doesn't stop there. Never mind that there are 30 residents per year, 4 teams, one cardiology teaching service, an utterly confusing calendar involving A, B, C, and D, call on every 4th day, P which stands for goodness only knows what on the calendar, different levels of hierarchy between interns, residents, and attendings, and only 1 day off per week. Never mind the 7 am sign-outs (and what the hell is a sign out?), pickups (huh?) and "caps" on admissions. And DEFINITELY, never mind that I look like an idiot as soon as I open my mouth and ask, very innocently, "what the hell is a sign out?"
I can't say I've been in very many hospitals, so I don't have any basis for comparison... but I'm pretty sure they imported the Labyrinth straight from Greece, put some hospital beds in it, and called it Hospital. I'm convinced that any one of these days, I'm going to make a wrong turn going from South Building to 4-West and run into the Minotaur himself. My greatest daily embarassment (actually, come to think of it, a ritual) is getting out of the elevators in the morning, walking purposefully forwards, realizing I'm going in the wrong direction, and making an abrupt 180. I think the fact that I'm wearing a white coat (and thus look like I actually know what I'm doing) makes it only more comical. I hope it will get better.
But the overwhelmingness doesn't stop there. Never mind that there are 30 residents per year, 4 teams, one cardiology teaching service, an utterly confusing calendar involving A, B, C, and D, call on every 4th day, P which stands for goodness only knows what on the calendar, different levels of hierarchy between interns, residents, and attendings, and only 1 day off per week. Never mind the 7 am sign-outs (and what the hell is a sign out?), pickups (huh?) and "caps" on admissions. And DEFINITELY, never mind that I look like an idiot as soon as I open my mouth and ask, very innocently, "what the hell is a sign out?"
Thursday, August 9, 2007
Family Medicine: The Happy Ending
My last day of Family Medicine. I should be cramming for my shelf exam tomorrow, but I just wanted to take a moment to make note of all the things I will miss after today. Yes... miss. I can't believe I'm actually getting nostalgic about a workplace, but these are the people I've been seeing day in and day out for the last six weeks, and for a person with utterly no life (a. k. a. med student), that's a big deal. They were like a second family! I'm going to miss the lady from the front desk who is perpetually asking us if we've eaten because she's seen med students hit the floor in dead hypoglycemic faint before. I'm going to miss the PA at the charity clinic who speaks Spanish so that even I can understand it. I'm going to miss the kooky attending, the attending who accused me of being in Slackers Med School, and the jaded (but jolly) fellow.
My preceptor was something else-- literally taking my hand and pushing it toward instruments while he performed procedures, holding onto my hand with the instruments until I was confident enough to do it myself. I sat in the hot seat and performed a cryo on cervical neoplasia in an HIV+ patient today, something I only wish all my other student colleagues could have the opportunity to do. I'm going to miss that teaching. I'm going to miss the nurses: sweet, crazy, caring, always prepared with coffee. I'm going to miss the little flags on the walls next to each exam room that made me feel so included-- red for patient, blue for nurse, yellow for doctor... and white for student (yes, student! we get our own flag!) in the room. I'm going to miss the schedules taped up at the nurses' station. I'm even going to miss the clock on the wall near the computers. OK, now I'm going a little overboard, but still... the place has its own rhythm and I had finally fallen into step, but now it's time to move on.
On a lighter note, I actually volunteered to do a rectal exam yesterday. You're probably wondering why a sane person wouldn't run screaming away from the opportunity to stick a digit up someone's ass. First of all, you've probably already figured out that I'm not sane, so that cat's out of the bag. More importantly, though, I was doing it for the patient's sake. You see, I was seeing a patient with Dr. Sausagefingers, and if you could just have a look at Dr. Sausagefingers' digits and then compare them to mine, you might see how compassion would move the heart of a young medical student to take mercy upon the sick and ailing, even at the cost of having poopy fingers.
OK, I'm done grossing you out.
My preceptor was something else-- literally taking my hand and pushing it toward instruments while he performed procedures, holding onto my hand with the instruments until I was confident enough to do it myself. I sat in the hot seat and performed a cryo on cervical neoplasia in an HIV+ patient today, something I only wish all my other student colleagues could have the opportunity to do. I'm going to miss that teaching. I'm going to miss the nurses: sweet, crazy, caring, always prepared with coffee. I'm going to miss the little flags on the walls next to each exam room that made me feel so included-- red for patient, blue for nurse, yellow for doctor... and white for student (yes, student! we get our own flag!) in the room. I'm going to miss the schedules taped up at the nurses' station. I'm even going to miss the clock on the wall near the computers. OK, now I'm going a little overboard, but still... the place has its own rhythm and I had finally fallen into step, but now it's time to move on.
On a lighter note, I actually volunteered to do a rectal exam yesterday. You're probably wondering why a sane person wouldn't run screaming away from the opportunity to stick a digit up someone's ass. First of all, you've probably already figured out that I'm not sane, so that cat's out of the bag. More importantly, though, I was doing it for the patient's sake. You see, I was seeing a patient with Dr. Sausagefingers, and if you could just have a look at Dr. Sausagefingers' digits and then compare them to mine, you might see how compassion would move the heart of a young medical student to take mercy upon the sick and ailing, even at the cost of having poopy fingers.
OK, I'm done grossing you out.
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