ER: last stand

Another hospital and my very last ER rotation.  This one is a big deal. A much bigger hospital system with many different hospitals. And allegedly my biggest chance to shine since I've had lots of previous experience before, but something was up with this place.  The people were fun, other students who were rotating, but the residents and the attending docs I dunno they were just blah. They didn't really want to be there, nobody was super pumped to be there. And the whole time I just couldn't put my finger on it. But I knew I didn't really want to go there, even tho they looked awesome on paper. This hospital system saw crazy amounts of pathology tho.

One of my best cases was 29 year old was dropped off at the ER all burned over his thighs, legs, arms and belly. He stated he "woke up and was on fire."  So we are in the ambulance with him in the back. He has already been intubated, as we must do with all burns over 40% of your body to prevent lung collapse (this is a long explaination just trust me on that) so he is unconscious.  When we get to the big hospital, they route us to the wash out bay.  Apparently, since the fire is of unknown origin and obviously suspicious they are going with meth lab explosion. Since that kind of a burn would involve various caustic chemicals that could burn hospital staff it means we must go through decontamination protocol and wash him off with a certain amount of water before they will bring him in the building.  Unfortunately, this guy has been crashing in the ambulance, with irregular heart beats and the heart monitor is not something that works well when sprayed with water.

Despite our attempts to fix it, they took off his monitor for 3 minutes to wash him down. Luckily, nothing unseemly happened and the doc got in to see him right away. It was quickly determined these burns were not from a meth lab explosion but rather from electricity. The muscle in man's leg was rock hard under those horrible burns. It was something I've never seen in real life until today, but something med school always warns us about: Compartment Syndrome.  The muscles and skin in his body were so inflamed from having electric bolts running through them, that they were expanding and filling his thighs to the point where they choked off his arteries and nerves.  He can lose body parts and eventually have his heart give out because of this. The doctor took out a big knife and cut a long, deep cut down to the muscle from pelvis to knee on both sides, his pink muscles squeezed out of the cuts like toothpaste. Then he did his arms, lucky this guy wasn't awake.   Apparently, he had been stealing copper wire from a live set of wires on a power line. And of course got burned.   He ended up having several of his fingers amputated because the flesh and muscle were so burned they would never be functional again.  This is a picture of his hand. I didn't get the best shot, which was his palm because the docs didn't want me to take pictures because of his critical condition.

Beyond that case, I did get to participate in a Code Grey or a Mass Casualty. We had a huge 10+ car pile up including a bus full of kids. So we called in all our docs and had people being checked over in hallways, closets, and 3 people per room. We had crazy parents running all over the place and causing a rukus, which didn't help anything and in the meantime we had several seriously injured adult patients from the same crash.  It was amazingly chaotic, just the way I like it!

We also had a inner hospital tradgedy. A 28yo internal med resident who went down to the ER on her shift and checked in as a patient because she had such a huge headache. And 6 hours later, she was dead.  Meningitis.  It was intense. Everyone around the hospital that day was crying and calling in to see if they could get antibiotic prophylaxis. Then her parents came and everything in the hospital stopped because everyone wanted to talk to them, docs, nurses, even some patients for whom she had made a difference.  It was just so close to home, I think it really made a lot of people think hard about their choices.

The final crazy story I have from this rotation was a 15yo boy who came in after playing paintball. He had taken off his helmet to wipe the fog from the visor, when a paintball nailed him in the eye. When I saw it was swollen to the point where it couldn't open even when i tried to pry it open.  THe poor kid was in shock I think, because he didn't really know what was happening. We got a CT scan to see what was going on and we noticed that the normal bulge of the eye wasn't there.  And sure enough, the eyeball had ruptured, we call it a globe rupture. There is very little likelihood that he will ever be able to see out if it again. They took him to surgery to see if they could save it.  This case was especially memorable for me, because I had to tell the parents what happened and that their son would most likely not have 2 eyes. Last I heard, the surgeons were discussing glass eyes with the parents.

Allergy: frustrating

So allergy rotation is 2 weeker.  And to be honest, its hard to focus on it. The doctor doesn't even see his own patients- he has his nurse practioner do it. Which is totally fine, she is very competant and has been working with him for 15+ years.  She knows what to do and what he would do.  But it makes it so boring for me.  I don't even see patients by myself I just shadow silently. It bores me to tears I actually bring my LAPTOP to work and in between patients have begun reading kindle books.  If you are a preceptor who is somehow reading this, let the students at least THINK they are helping or doing something. It is so hard to have gone over a year doing things, at least training to form opinions or learn things, to go back to being silent in the corner.  I'm no longer satisfied with just being there, I want to engage.

Anyhow, sorry no pictures unless you want endless rashes....  which i don't care enough to even take pictures.  I suppose it also doesn't help that i have serious romantic troubles and also maybe if i learn something rather than staring at walls, i will post more.

Update: Trial by Fire

I don't know if everyone feels this way, and maybe its because I am the person who is choosing ER as a career, but I find challenge enticing. Not just enticing, but thrilling and desirable.
So when the program I interviewed at recently, told me they have all of the qualities below, I found myself undeniably attracted....

1- 110,000 inner city patients.  This does not feel like a program with a 'large patient volume' its more like a 50 bed clinic in the middle of Africa. They are SWAMPED. Patients actually wait DAYS in the waiting room. Most ERs have a patient per room and sometimes in the hall by the wall, all neat and organized. But they actually have minimum of 2 patients per room and patients in the middle of the hallway, at the nurses station, at the entry, they even converted the staff locker room into a pelvic room. There literally is NO space there isn't a patient.

2- Underfunded & Unionized nurses. This doesn't just mean that there aren't as many resources or staff. It actually means that once the hospital hires a nurse, they cannot fire them, for any reason. So they cut their costs nad their staff. The ER has on any 1 shift, a total of 5, yep as in # of fingers on your hand, nurses for this HUGE ER.  For residents, this means that they put in their own IVs, draw their own blood and urine labs, transport the patients to and from radiology, and if needed transfer them to the floor upstairs for admission.  The nurses give medications, unless its needed stat. If you want anything done fast you have to do it yourself. There are a few techs that do EKGs, but for the most part you learn to be a doctor and a nurse or as some people call it: self sufficient.

3- $$$.  This is located in an incredibly expensive city. I don't think its giving anything away to say its in New York.  And to pay for rent, parking, and food is just ridiculous!  Plus working all crazy hours is not condusive to public transport. Espeically for unsafe areas of the city, alone, in scrubs. I'm actually worried I wouldn't be able to afford rent much less all the cool things I could do in New York.


However, with all these patients and this huge workload-- there isn't much time left over for teaching.  All the residents I talked to said it was literally a 'trial by fire' residency.  Where they were put in multiple situations that they had no idea what to do next and nobody to ask questions to.  Several residents say they spend the whole peds shift with a nurse and no attending.  It was crazy!

But secretly, I love this idea.... I WANT to know if I will have what it takes to undergo a trial by fire. I WANT to be so overwhelmed and overworked that I have no other choice but to learn to be a kick ass doctor. I WANT the confidence to know I could walk into any situation, and when I don't have any idea of what is going on, I still can succeed.  This is the ESSENCE of what ER represents. And... working and training at this place would have the potential to be exactly what I want.  It would be the crazy dramatic medical drama that you see on TV.

Of course, that also means that in reality world, it could also be horrid. Often the drama in the shows we watch is not the norm. And overcoming ALL odds is rare and freakin exhausting. I am about average intelligence-- do I have what it takes to get no feedback, no real teaching, and after a hard overworked day still go home to study to save the patients I may encounter tomorrow??

I honestly don't know. And that is what makes me hesitate. To take on this challenge and fail, would be a disaster. Not only would my confidence be shot, my cynacism be maximized, but my skills as a physcian might not improve. I might actually learn to hate medicine, which is a big risk.  Too big maybe?

ER: the Ear

So. Let's start with the pictures first.  So +1 to this place, they make ALL their patients sign a waver as they register that we can take pictures of them for teaching purposes. So that means I can totally take pictures of anyone!!

So here is one of my most interesting cases.

32yo M presents with ear pain after altercation.  Pt states was drinking at bar and taking the keys from his husband of 14months. Pt states that his husband got mad at him and had been having some psych issues including bipolar and testosterone shots.  Out of no where, he leaned over and bit his ear off.  That's right savagely, with his teeth, bit his ear off. You can see down to his skull in the top there, down that large hole. The amount of ear left is actually very tiny and dripping blood.  The crazy facts I learned during this case is that human bites tend to be dirtier (aka more infections) and more savage tissue damage than animal bites. Look at there photos.

So what happened?  So we found the ear after scouring his car and finding it between the seat and the console. (yeah never knew that was in the job description did ya?)  And the plastics people came out and said the skin was dead, but they would use the cartelige to rebuild the ear and then add a skin graft.  The problem was the plastics guys were telling me that his ear would never actually look normal.  Also, he pressed charges against his husband, whose call he took while I was cleaning it out. Apparently he was complaining that police officers were going to arrest him and when he refused to drop charges, told the cops that the patient was 'beating him.'   Ridiculous.  I bet $50 tho that they didn't divorce, because he took his call.... twice.  Some people don't learn.

ER: audition #3

So I am at yet another hospital in yet another state, living in a closet sized room in some abdandoned wing of the hospital.  At least they give us free, unlimited hospital food and the cafeteria is open 24/7. :)

This ER is similarly big and a trauma 1. The ER is organized into "pods" which are about 20 rooms in a circle around the nurses and doctors station. 1 pod is fast track, 1 pod is trauma/ life threatening and 1 pod is middle stuff.  This seems to be a very popular set up for newer ERs. There are no windows and each pod is a different color, this means working night shift or day shift there is no difference and this isolates us in our own little ER world.

This particular ER uses a medical records system called EPIC, one of the big ones that everyone seems to like.  It is a bit different to learn, but as a 4 year, I put in orders including dosages and knowing which medicine specifically to be approved by the attending.  It lots more pressure than simply just presenting.  I am hoping to learn alot.

I also had my very first interview for residency. I now have 5 interviews again from DO places, and now 1 MD here, a courtesy interview for rotating here. This is a typical ER residency practice. Since many people only get 2-3 places, they assume if you are rotating there that you really like the program. Since they get to see you in action for 30 days most places will give a courtesy interview- which counts as a real interview.

In my first interview, it was different and as i expected all at the same time and in the end I liked the program, and will include it in my rank list, if i should decide to go DO.   However, I met a girl from my med school there- also interviewing. I didn't know her well but we chatted in her car for about 1 hour afterward. It was helpful because we could compare notes of where we got interviews, where we applied, discussed board scores, etc.  It was nice to know I'm not behind yet.  She went to the ACEP conference this year. They had a bunch of program director there and they announced that ER is more competitive this year, on par with surgery.  And that they are getting so many applications they are running behind.  So most programs have not offered interviews yet.  I feel relieved at this. I will wait another week or two before deciding to apply to 10 more programs if i haven't heard back....

more after my first shift....

ER: concluding with bubbles

Well, in the end I know this program is somewhere I want to do my residency. I feel like i know these people and this place so well that I could function here.  But when I left this rotation, I had to take a 30 question quiz that I did not do well on.

However, I did see this amazing case. Something great to remember them by.  It was a rare slow day in the ER and I was desperate to see something anything, because being idle means I have to think about that stupid quiz and what that'll mean for my chances getting in here. So finally EMS calls and reports they are bringing in a patient from an unknown trauma with unknown injuries. This report is... at the very least vague and unusual. So I decide, I'm going to take this case with the resident.

44yo M comes in on a stretcher,  he is awake and has blood on his head. EMS still doesn't know his story or what happened, they picked up from an apartment building. They couldn't find blood or heavy objects or any clues.  So we go all out, like back in my days of trauma service, priority #1: find out what happened.  We get whole body xrays, CT of the brain, STAT blood work, and begin cutting off clothes and asking questions.  The patient answers questions, but he seems not to remember what happened or who called EMS, and he also seems a bit off.  Either he's had a significant head injury or he is mentally delayed. Everyone is rushing around listening to patients heart and lungs, looking at lab work and xrays, when I do something that nobody has really done yet.  I touch the patient.  Just on his shoulder, skin to glove. I meant it to get his attention to ask more questions, but something is off.... his skin feels strange. I put my other hand on his chest, then quickly run my hands down his arms, abdomen, and legs.  Its everywhere. What is this?  I call the resident, feeling stupid because I can't explain what i feel.  It feels like bubbles, like that plastic bubble wrap you put in packages, only the bubbles move when i push on them.  The resident looks at me like I grew a second head, but since he's been working with me for a year now, he does something I don't expect.  He believes me.

He gets into the room and starts feeling the patient, yep he feels it too. Soon he calls the nurse and everyone outside looking at grey swirls of brain tissue on CT to get in here. The patient is being gently mauled by hands feeling all over his skin. and sure enough the CT shows it: MASSIVE airpockets all throughout his body.  They aren't just under his skin like we thought, they are between his muscles, around his heart, around his fat cells, and even in some organs.

This case was just so crazy, that i did steal this very illegal CT photo for you.  Its the actual guy.  Now subcutaneous air pockets can happen in patients who perforate a lung or intestine. But usually its located only in one area. The amount of pressure it takes to put air in our tissues is vast. Air outside of the GI tract or lungs is called "free air" and always a warning that the person will be on the operating table within hours. It is often the first and only indicator of something life threatening. But even the surgeons stared at this guy in awe. There were no holes in any organs they could find, but the air was everywhere. They couldn't take him to surgery because we didn't know where it was all coming from. The first theory was that it might be from a rare condition called Boerhaave's syndrome, which is a rupture or complete tearing of the esophagus.  This is life threatening and is rather rare.  The problem is we couldn't find the tear in the esophagus with the CT.  So, basically nobody knew what to do with him.

While the trauma surgeons were calling every specialist in the hopsital looking for possible other answers, we as ER were trying to come up with a way to fix his symptoms. He had no head injury and no fractures. Besides there air and abnormal but confusing lab results we had nothing to go off of. Usually for air in the body we cut a hole to let it out, but  making tiny incisions in the skin whereever there was a bubble was just assinine, he wouldn't have skin left!  So in the end we admitted him, put in chest tubes to relieve air around his heart and lungs, left a tiny air in the middle of his belly and admitted him. The surgeons told us they would be doing special studies that day to see the esophagus and make sure that wasn't the cause.  And they took him upstairs.  I never did find out what it was.... as is the true spirit of ER. :)  What a send off.... i got to conclude my month with bubbles.

Update: Residency Application

so for kicks since its a huge part of medical school, i am posting about my application process.  I'd liekt to say after 53 programs I got 2 interviews thus far that are set up. 1 is still pending.  All of them are DO so far. MD programs seem to take longer... or so I hope.

Anyway, for those not in medicine you might want to disregard the following.

ERAS is the program/internet site thru which all residency applications happen. This site usually opens in July. I honestly didn't start filling mine out until August because I was focusing on boards.  That said here are a few pearls for other students:

1- fill out the 'application' tab AS SOON AS POSSIBLE.  This is a tab that you can submit to be verified before you actually send out any applications to residency places.  It takes a few days to be verified so get it done early. Once you submit this section tho, you cannot go back and edit. SO make sure you take some time. It took me about a day to fill this part out, while watching TV.

2- After submitting my application tab, I then started to work on the 'documents' tab.  This tab includes personal statements, letters of rec and releasing your scores. If you took USMLE, you do have to release them to MD programs. Not DO.  This tab always takes longer than you want. So go ahead and release your scores, you won't have to pay for them until you apply to your first program. Also you have to go in an enter your letter writers info and you're required to finalize them as well. This is so you can enter as many letters as you WANTED by the people you WANTED. Then when they actually send the letter to the school, you can finalize the letter.  Hope you've been asking for those letters in third year.

3- Your personal statement(PS) is what really takes forever. You never really get it quite the way you want. So give yourself probably a week to get it right (or more). Remember if all you are waiting on is  your letters or PS go ahead and submit your application to be verified. So there are 3 unwritten questions you must answer in your PS: why this specialty, why pick you, what do you want to do in the future of the specialty.  Lots of ppl fudge that least question and instead answer what they want in a residency program. Its up to you. Be sure you have at least 2 other people edit it before you submit. 1 of your editors MUST be in medicine.  You are allowed to upload multiple PS. And you can edit them UNTIL you start submitting applications.

3.5-  ** many programs give you the option to upload your picture, and many highly suggest you do it. However you DO NOT have the option to use your school photo. Please go out and get a professional photo done. easy places are like JCPenny. These pictures must be emailed in digital form to your school in lots of advance. So be sure this gets done. I got pictures taken for my VSAS application third year and used the same photo.

4- IF you get frustrated with your PS you can always move on to the 'programs' tab for a few days. This is where you must search, select, and assign documents, PS, letters, photos, scores to each program.  and yes you must do this with every program. Eventually you also apply and pay money under this tab.  It is here that i recommend you research your programs.  You can search by specialty, state and DO vs MD. They also include the residency specific website.  Remember that you can select programs before you submit so you might as well get your selected programs pool started.

To apply to programs be sure you have a few criteria. For me it was a trauma level I or II, since I'm ER I wanted 60,000 patient visits per year in the ED minimum, also I wanted programs that had a DO in their program (i found this out by going to each of their websites individually and looking).  In the end I applied to 53 programs. This was approx $600.  I applied to 11 DO the rest MD.

5- When you apply remember that you will be paying in 'sections' and that your bare minimum # of programs should probably be 10. after that you can decide how many more based on how competitive your specialty is and how competitive of an applicant you are.  The general rule is 10 interviews mean you will match somewhere.   Sept 15 was the big day this year when MD programs started accepting applications.  That was a saturday, I submitted this day and 19 of my programs downloaded applications on saturday. So get them in early. I'd say the first week if you can.

6- Once you start submitting to programs, you are still able to upload NEW letters and assign them to programs so there is no excuse to wait for letters or scores. Its better to get your application in and call them once the new letter or score is available for download. Many programs will wait for all your letters or your scores... and many will offer interviews without waiting. Don't miss out. Also you can always add programs and if you want, ADD PS. For every specialty you apply you'll need a diff PS.

7- Dean's letters come out Oct 1st. No school anywhere is allowed to put them up before Oct 1st. Many programs ask for the letter early, but no program gets them. So don't let them make you feel guilty. Also students are allowed to see their Dean's letter, so keep an eye out for your letter in your email.  Don't wait until Oct to submit if you have a chance.

8- last but not least, on the very top right there is the ADTS link, it is here where you can see what documents if any each program has downloaded. This is way you can track to see who has downloaded what. if some program hasn't downloaded, or you haven't heard from them in 2 months- then you can call and make sure they had no problems with your applications.

9- You must pay and register for the match (either DO or MD or both) BEFORE DEC 1st. DON'T MISS THIS DEADLINE or you CAN'T match. If you're not sure, enter both and drop out of one or the other.

ER: presentations

I have sad news. Due to some resident posting a picture of a liver on facebook, our hospital is up in arms about us no longer being allowed to take any pictures. *Sigh* this really really sucks. I have seen so many good patient photos this month. I realize that posting pictures on facebook is idiotic, but can you really call that picture of a liver a HIPPA violation?  I mean who could say, yeah that's so-and-so's liver?  You would have no idea if it was male or female or even what race. And we do multiple liver surgeries in the day so there is no way you could know what date and assume its this one person. I call this bullshit. Most patients are happy to have their pathologies looked at by a room full of doctors and discussed. Plus how else do we get photos for our textbooks?  So my blog will be full of photos from google now... which disgusts me somewhat. But now you know. Maybe other hospitals i go to will be less freakin-out about it.

So at this point you've had exposure to trauma and surgery. So the big cases aren't the impressive ones this time. Now in the ED, they are judging me to see if i'll make a good resident. And that is almost exlusively determined by how I present. In the ER, the presentations are hard. You have to display your skills but keep their attention, you have to balance giving them the basics with letting them be confident you did a through exam. So I decided todays stories would be about crazy presentations....


First, is an elderly man who comes to us in the middle of the night from a local nursing home. The patient is demented and barely knows his own name. He cannot answer any of my questions and this means the pressure is on to do a through physicial exam. The complaint on the chart and EMS squad says his PEG tube is cracked (if you don't remember what a PEG tube is, you'll have to back to my surgery months).  The poor guy gets scared everytime he is able to see the tube because he has no memory of ever having it. I look all over the stupid tube, i even pull a tiny bit out of him, but i see no crack. I grab a syringe flush from the nurse and flush water down the tube, nothing leaks no cracks to be found.  And I decide that since I'm on my audition I'll call the nursing home and find out what is going on .  The nurse who sent him over talks to me for about 5 minutes about how the tube leaks and how there is a crack at the top of the tube near the cap. Finally I realize. The nurse is describing to me the part where the plastic tubing stops and the cap starts. She finally says yes, it comes off if i pull it hard enough.

Now I tried. I really really tried to make myself as least judgemental as possible, when i told her that typically all PEG tubes have a cap installed and while there are a few models where the tube and cap are connected, most PEGs are seperate parts. This is how its supposed to be. Immediately when i hang up, the attending comes up to me and says "wow that was a bitchy tone." I still can't figure out whether this guy was joking or not.  Then i had the pleasure to try and present this patient.

"so why is this guy here"
"the nurse thought he had a crack in his PEG tube."
"oh. Well, where is the crack?"
"there isn't one. I flushed it, there was no leaking. I called the nurse. It seems she thought where the tube and the cap came together was a crack."
"so what you're saying is the nurse didn't know what she was talking about?"
"yes."
"aren't you alittle young in your career to make those calls?"
"not if they are this obvious, sir"
"aren't you a little arrogant shit."

So that went well. I am definetly going to get a residency here after that.... *sigh* can't win.


Another case was actually the same night. the complaint on the chart read "sumac poisioning"  and you konw immediately that this patient went on the internet and self diagnosed or has had it before.  It was also weird that this person had it for 5 days and it was 4am.  So i went in and tried not to be too surprised by how the patient looked.  The chart said the patient was 55, but I couldn't figure out if it was a male or female.  There were boobs but, manly other parts.  Anyway I just took the history of this chart and the patient showed me the rash, which was a contact dermatitis. I took a through history and then went out to present.

Most presentations begin with an age and sex of the person as well as the most important big symptom/complaint they have. Like :  89yo M presents with chest pain.  or 43yo F complains of abdominal pain and fever.

I take this structure of the presentation for granted. So I started saying " This is a 55yo...." and then i get stuck. I'm like is it male or female, male or female... how can i be a doctor if i don't know this....
So i lean in to the resident and say "I don't know if the patient is male or female" And the resident immediately laughs and puts his head on the desk.  "I don't know what to do with you med students" Just as that happened, the attending came up right behind me and asks the resident "you seen the patient in 17?"
"No sir, the med student was just reporting."
He looks at me "so what's your vote? male or female?"
The residents eyes get really big. "what is going on?"
"i bet transgender, pre surgery." I say.
"i'm going to see this patient," the resident heads off...
"wait don't you want to know why they're here?" i call, resident just keeps walking. completely ignores me.


So for those of you who don't know... a basic presentation goes something like this:

"56yo M complains of chest pain x4 days intermittently that he describes as squeezing pressure. Episodes last 2-3 minutes and are relieved by sublingual nitro. Tonight he took 3 nitros but the pain was not better and has lasted 4 hours. Pt states pain shooting down his arm, no sweating or shortness of breath or back pain. Denies fever or cough. Pt has 3 stents placed last year, no previous MI, but he is diabetic. EKG shows no ST elevation but some T wave inversion in v1-v3. Pt is tachy and BP 210/48. He looks like he's in trouble to me, i'm worried about a heart attack. I think we need to get an IV in him stat, the nurse already gave aspirin. I recommend chest xray, heart enzymes, chest xray, and some pain medication.  Here is the EKG. "

So for those unfamiliar, presentations should include:  what complaint is, how long its been there, description of pain, what makes it better and worse,  what patient has tried, if the pain radiates, if he has had anything like it before, what made him come in today.  Also you must include pertinent risk factors and negative findings.  This can be the trickiest part of the whole presentation and i think its the trick to impressing them. I showed I was thinking about heart problems by including high blood pressure, asking about diabetes and previous history of stents.  Including what the patient did NOT have, means you know what to look for and shows what you asked.  In this patient, the list of things that could be causing his chest pain is LONG. So to show I've ruled out some of the causes I include the negatives.  Chest pain that radiates to the back is a symptom of aortic dissection a big big problem, but he doesn't have it.  He also don't have fever or cough, which means is probably not pneumonia or a heart infection. I also listed his vitals and physical exam, what's been done, and then the biggest part that is NEW for fourth year is MY PLAN.  I told them what I wanted to do and also that I had looked at the EKG and the test results.  I don't always have a plan, which is bad. But i always try to come up with an general idea of tests I want to run to find out what my diagnosis is.  Oftentimes, I'm wrong, but the key is they know i"m thinking about what I would do.

For auditions, having that plan and including those negative findings and risk factors.  This is what I want to master by my rotation in december.

ER: med wars

So med wars is a BIG DEAL.  It happens all across the country and is divided by region. Medical professionals (including residents, med students, nursing students, nurses, etc) are all encouraged to participate. But it usually ends up being residents and usually ER residents, maybe because they have the time or maybe because they tend to be outdoor people. Who knows.

They pretty much go to a national park, camp and then do a sort of adventure race competition during the day.  Each team has 3 people. The one i saw they began at the starting line in canoes. Their task was to make it to the first "station" within the hour.  They had to paddle some 5miles, where we were waiting. There they were given a scenario where an event happens and someone is "hypothetically" injured. They must make medical decisions in front of judges (like me!) and  we grade them.  This year's theme was an ALIEN INVASION! The first station they were told that purple clouds spouting lightning descended upon them and one of their team members ended up with a severed leg.  They had to put on a tourniquet and carry the patient out of danger before they could get their next clue and map.  While they did not sever anyone's limbs, they did have to apply a tourniquet and carry their member up a hill.   Each map had only enough information to get them to the next station, where more plotline was discovered and more wilderness medicine challenges had to be completed. Along the way there were "mini games" which included trees with signs on them asking medical questions, like when to give which medication, lightning safety, or which animal is associated with which disease.  Many of the stations were heavy physical work, including saving a baby from aliens by swimming through a lake to rescue a baby (baby doll) then swimming back without getting the baby wet. Of course then they had to do baby CPR.  In the end you had to fight the aliens and save the world. Can't tell you how, it would ruin the surprise...

The total race ended up being 20 miles including canoeing, swimming, hiking, and going through a swamp. I was a judge for many of the different stations. There were a total of 5 stations and 25 mini games. Time was a factor but they also had to get as many of the questions in the mini games right as possible, this would subtract time for you. Players start at 7am and most don't finish until 5. We had several that got lost and had to send out search parties.  This whole situation is celebrated at the end with  hundreds of pizza, snacks, drinks, soup, chile, ice cream, cookies, brownies, hot dogs, etc. Basically the biggest bonfire you've ever seen and then we sit around and camp another night talking about how crazy that plot line was or how hard it was to wade through the mud, etc.

Residents that win the med wars, get bragging rights and often get to be the makers of next year's race. Personally, i was heart broken I didn't get to be on a team. It looked so fun! But at least I got to go. This year we had 35 teams of 3. So there were lots. And it was SOOOO FUN.

Next year, i'm making a team. You all should too!! Go look it up by your region and enter your team early. Besides 3 days off it only costs $12-14 per team to register. All that money goes towards food.

ER: audition #2

So I'm back in the ER. I'd like to say that the smell of blood and urine and the anxiety hanging in the air excites me yet again. But this time, I am just numb. I feel like my confidence has been shredded into tiny pieces--- what with all the residency application stress of writing my personal statement, getting my lower than average step 2 scores back and the reality of the application submission opens saturday I am just exhausted and way too over stressed. Not to mention this is now audition season and next several months will be having to prove to everyone around me that I am a smart candidate that they should want.  

I go to work and instead of looking around at patients and stories of those in the ER, I stare at the first year interns instead. Wondering what they did to get in that spot and desperately hoping I have what it takes.  The whole of it exhausts me. I am tired of feeling inadequate and trying to prove to them that I am worth something. Not to mention, the prospect of dozens of exhausting interviews to try and make my mark--or worse no interviews at all...

The good news is that a few residents here have said they have my back. These residents get to vote when our applications come through. So now I have to decide if i want my audition rotation to count as my interview or if i want to come back for a formal one.  The option to save money is always nice, but I don't want to be out of their minds or not get a chance for the faculty to remember me.  So I don't know what to do with that.

I was also invited to Med Wars, so I'll have some pretty good stories then.

Since I have only done 1 shift in the ED, i'm going to take this opportunity to say, I'm applying on saturday for residency in the ER.  I have already sent 11 applications to DO places and i will send 30 more to MD places.  After that it is all a waiting game hoping that I get interviews and don't screw things up.  I'd like to chronicle here some of the struggles I've gone through and some of the answers I've realized, but since there is a small chance that while I am applying someone else could steal my answers, I won't risk that right yet. HAHA nothing like feelings of inadequacy to bring out my competitiveness......

Radiology: medical humor

So radiology was a bright idea of mine. I signed up for it knowing that I would be studying for my USMLE step 2. I wanted a quick and easy rotation and I wanted to be good at radiographs for my ER auditions.   This was a great idea in theory, but I can't say I couldn't have learned what I got out of my rotation in a single day.

The structure was to watch the test being done in the morning, and then watch radiologists 'read' them in the afternoon. Needless to say, this rarely ever happened.  Watching a single MRI, CT, ultrasound, is enough for me to know what i need to know. While watching the actual test wasn't all that great, I was happy to sit with the radiologists and read the panels.  I can see how some people would be attracted to this lifestyle. While many people don't give credit to these guys sitting in the dark looking at shades of grey, there is a real art to it.  And the amount of people contact is vastly underrated.  Physicians of all specialties are constantly calling and asking for clarification or questions.  Not to mention the nervous patients in the hallway, who often want to meet the radiologist.

I did have a single day in interventional radiology and I must say, this specialty might be the best kept secret in medicine. You interact with patients all day long, doing diagnostic procedures. Things like difficult lumbar punctures, artery embolization removal, and any other procedures you can think of. And when you are done, you call and tell other doctors the answer then move on to the next patient.  So if you like procedures, patients, and knowing answers who wouldn't like it?  For me, it lacks the urgency of the ER, but it was pretty close to awesome.  Since I was not able to grab any pictures, I decided to post on here a few super funny ones the Radiologists showed me.

During that day, I saw a 14 year old male with a large thrombus in his ARM.  Now for those of you not in medicine, a thrombus is a blood clot in your vein. If the blood can't leave the area, the area will swell. Thrombi can happen anywhere in your body but its is mostly in your legs.  Certain conditions can cause your blood to be sticky or clot easily, some of them include: pregnancy, cancer, or taking oral contraceptive pills.  But a clot in a kid happens very very rarely and for a clot to be in the arm is even more rare.  So it was probably a once in a lifetime patient.  The interventional radiologist did end up clearing out the clot, but we never did find out why the kid had one.

The only other neat story I have from this rotation I wish I had grabbed the CT.  It was a 'stat' read on several CT images for a patient in the ER that had been hit by a car. We were discussing the pneumothorax in the lungs (a hole that was popped in the lungs) when suddenly the radiologist leaps up and yells shit and calls the ER frantically. He asks for the resident and shouts this patient has an aortic dissection, call the trauma surgeons! Luckily, the resident had already called the trauma surgerons and the patient was whisked off to surgery. I never did find out if she made it. But it was intense. :D

*the majority of these images came from this website.  It was a pinup calendar that a radiology company (Eizo) produced to help with marketing. I thought it was hysterical. Several radiologists had it hanging up in their secret radiology 'batcave" :)

cardiology: cath lab

I'm a bit frustrated with this rotation, as nothing is expected of me. However, I did get to spend a whole day in the cath lab after I requested it.

It was an interesting day. For the most part, it was placement of stents and pacemakers.  It was almost like a mini operating room. The interventional cardiologist confessed to me that he actually wanted to be a cardiothoracic surgeon but knew since he was an international medical grad, he became a interventional cardiologist. He said that now he is happy, not only does he like his job, but fewer and fewer cardio surgeries are happening these days.  Most people opt to have procedures done by him, with all the advances in technology, as opposed to getting surgery.  So his business is booming. These pictures are him at work. He doesn't have to boast about how good he is at his job because his reputation proceeds him. Almost everyone in the hospital knows how good he is.

I got to see it first hand, when the ER called. A lady was complaining of chest pain, and her EKG showed she was having a heart attack. When a heart catheterization occurs, the doctor makes a small whole in the leg and inserts a small wire tube through your artery all the way to you heart.  We inject dye and take pictures of your heart, watching the dye be pumped through.  This is how we identify which arteries to your heart are blocked. Then the doctor inserts a stent, a metal wire mesh to hold open your artery, as pictured here.  Stents are a genius invention, a way to keep the heart beating despite what you have eaten and how much you haven't exercised.  But for all the genius of the stent, it is only a bandaid. I think I've posted before about how disappointing it is to know that even tho this wire is holding your artery open, it didn't fix the blockage, it just smashed the cholesterol against the sides. Its not really a permanent fix, but then I guess I don't know what is in medicine anymore.

In the end, it was an educational day. Repetively seeing both emergent and non-emergent pacemakers and stents. I understand now what happens to my patients as they go through heart problems and fixes.  But I also saw that I don't really want to be a cardiologist, exactly like what I learned in my Anesthesiology rotation. *sigh* I'm sorry if I repeated what I had already said there, but it surprises me how much of a waste this rotation was for me. I am sad that I did not learn any new information.

let's talk cardiology....

So, on to more medicine. Cardiology is a weird rotation. Hours are usually from 8am to noon. Which sounds short, but it can be long and very very involved.  Most patients in cardiology are complex, because patients who have heart problems also have other problems. The best way to show this is to share the risk factors for heart disease:

• Diabetes
• age > 70
• high cholesterol
• obesity
• smoking
• family history of heart disease men before 50 women before 60.   

There are a plethera of criteria lists and risk factors in medicine but it seems to me that the lists in cardiology are particularly applicable. Almost every patient we see fits at least half if not more of this list.  On top of those risks patients often have renal failure, liver failure, and GI problems.   Its never just controlling the heart symptoms, it always involves working around their other problems. We can't give certain medications if you have renal failure vs. liver failure.

Another complexity prevalent on the heart service is compliance. The vast majority of heart patients don't 'feel' sick. As we all know, high blood pressure is alot like high blood sugar, you don't feel sick despite the fact your organs are slowly dying inside you. Its easy to sit on a couch with swollen legs and say you feel fine.  (most heart symptoms don't show up until you NEED a high blood pressure, like exercise). Oftentimes, noncompliant patients can be given a better education and it will at least make a dent of a difference.  But a large majority of patients-- no matter how often we try to explain it--- don't want to understand that taking their blood pressure pills or controlling their diabetes can prevent them from going blind or starting on dialysis. It can prevent a heart attack even. We call these conditions 'silent killers'. This aspect of patient stubbornness is particularly frustrating for me and makes it hard for me to care about a patient who won't care for themselves.

The last complexity is blood thinners, some examples of these are Coumadin, Heparin, Effient, Plavix. These medications are often very important to prevent blood clots, stroke, and a repeat heart attack. But these meds are a big pain in the butt. Everytime a person bumps something, hits something too hard, etc they get a bruise. Every cut bleeds excessively.  Nose bleeds become a nightmare.  Nobody wants to be covered in bruises and lots of patients hate it.


more info later....

Study Month & $$$

So, for those of you reading this, you should know July is my study month, so i won't be updating til Cardiology starts in August.

So, I thought i'd give a little tiny glimpse into the more complicated life of a med student.  And what better way to understand than to talk $$, especially when applying for residency. Because so many people out there don't understand exactly how much it costs to become a doctor. So here are a few fun $$ amounts that I have to deal with:

So Licensing exams. There are 3 of them that every doctor takes.  Step 1 is written and after second year. Step 2 is both written and oral after third year.  And Step 3 is written, only pass or fail and is taken your first year of residency (also known as intern year).  This year these are how much it cost me.

• Licensing exam - Step 2.   Written:  $500   (i'm taking 2 the MD & the DO)
• Licensing exam - Step 2.  Oral:   $1,500 + plane ticket + hotel + rental car (this is a 2 day event)

Total cost here: $2,500 to simply take my exams + plane ticket + hotel + rental car

Actual Application process:

• Applying to programs costs money.  So the first 10 programs in 1 specialty cost $92.00 flat fee   for 11-20 programs add on extra $9/program   21-30 programs add on $15/program   and 21-30 programs  add $15/program   31+ programs add $25/program    (i plan on a minimum of 50). Some people apply to more than one specialty. I don't know if i can afford it.
• release for my licensing exam scores costs $70 each (so x2)
• transcripts from the school cost $5 1 time fee
• registration for the MD match costs $50
• registration for the DO match costs $60

So generally to only apply the first go round I'm looking at $1,237 plus the cost of my exams, plus any extra fees.  Don't forget that if the residency program likes you they will offer you an interview.  This will cost plane ticket + rental car + hotel and 3 days of your time for every interview.  Most interview seasons last about 3 months and almost everyone's rule of thumb is that you need 10 interviews to have a good chance at matching into a residency program. By this time next year it will probably be 15.   So that's a lot of money and plane rides in a 3 month period.  Lots of suits and questions and travel and being tired. So yay.  That's my future if i pass step 2.  Yay.

Plus it doesn't help that I am officially going to be close to a million dollars in debt when I'm out. This means my minimum monthly payment is going to be over $3,000/mo for the next 10 years or more of my life.   Is there any wonder why so many people aren't a fan of capping doctor's salaries? Or so many don't go to medical school anymore?

Also, Is there any wonder why I have no motivation to study for this exam?  It is never-ending. Now I have to go force myself to study.

ER: summary

To start, lets go with a few of the cooler cases that I have seen.

The first is a mystery overdose. This is always why ER docs get paid the big bucks because no other doctor does this part of things (aka- if we have no information or even guesses they send in the ER doc). The patient isn't exactly unconscious but she might as well be.  All we know is she took some pills. She's seizing and doesn't really know what's going on around her. Her blood pressure is a roller coaster of too high and too low and nobody seems to be able to tantalize her enough to get her to the ICU.  It also doesn't help that her husband and her boyfriend are screaming at each other arguing over what she took and whose fault it was.  We talk to them separately and they give us two different stories of what she could have taken.  It gets frustrating. In the end, I get a list of all of the meds they had in their house and start looking up toxidromes for all of them. I figured out that bendryl was among the things she took as was wellbutrin, an anti-depressant and anti-smoking drug that increases your likelihood of seizing.  Neither of these drugs have a reversal agent so to start, i just recommended fixing all the electrolyte abnormalities that could cause a seizure-- like too low sodium or too high potassium. Eventually the seizures did finally slow and the lady admitted to taking aspirin as well. We quickly gave the antidote although it may not be as effective because of how much time went by. She finally went up to ICU and i never found out if she made it.

There was also an elderly male who came in with hypotensive crisis with multiple bouts of nausea and vomiting lasting over 2 months. We couldn't figure out why and apparently neither could anyone else. We had given him 2 liters of fluid and mulitple pressors and still he wasn't getting better.  He was in renal failure and had been getting worse because of his diabetes.  It turns out he also had a heart attack 2 years ago and was on a huge regimen of meds.  In a very cool last ditch effort, on the docs gave a 5mg bolus of glucagon which is the antidote to Beta blockers (a heart medication), which fixed him right up.  Apparently, because the kidneys were failing and were unable to clear the beta blockers out of his system so everytime he took a pill it was increasing in his system rather than clearing.  He had so many in his system that his heart simply couldn't recover and therefore it was getting worse and worse.  Talk about a very cool last ditch effort. Way to throw the kitchen sink at him.

Also here is a photo of this 8yo's rash, you should know rashes are an ER docs worst nightmare because we see them all the time but really derm is so subjective and so random that it is hard to diagnose and seems almost impossible to treat.  So most docs run the other way or force the medical student to deal with it. (ahem). So this rash literally covered him from head to toe for the past month. The reason I got to take a picture of  it was because nobody could figure out what it was. He had been to other ERs where they'd established: it wasn't hives. It wasn't scabies. and it wasn't poison ivy. no viral symptoms. All of which he had been treated for before today with no improvement. His rash was getting worse and he hadn't had any meds for a week. So we admitted him because we didn't know what else to do. This poor kid had to deal with these all over himself and nobody had any idea how to help.  The sad part about being an ER doc: Never did figure out what it was. Hope they figured it out eventually.

Now that i'm almost officially done with this audition rotation, I don't have anything clever to say.  I don't know how I did or what they think of me.  In general, I just am fearing studying for my next liscensing exam.  SO much so that I sorta just.... don't.  Which is very very bad.   Also the application program that allows us to apply for residencies opened. And I still don't have my personal statement (the essay that states why I want to be an ER doc) written. Or even a good idea conceived.  *sigh* So much to do and so much apathy....

ER: general stuffs

So the ER. Still a thumbs up on my end. But its hard to be positive. There is so much I don't know, so many questions I get wrong. I wish I was one of the students who just remembered everything somehow. That's not true because half of this wasn't covered anywhere. How the heck do they know this stuff? I don't know it.  I feel quite a long ways from being ready for intern year. I know nowhere close to what everyone else seems to know.  Anyhow, I suppose I should say its easy to be discouraged when I put lots of pressure on myself. And this is my first rotation in the ER.

Lots of people have been asking, how did you pick this program to put so early in your schedule? This ER is one that is a program in the middle of my list, something I'm not broken hearted if i don't get but something I'm excited to get a letter from. I've heard most of your rotations should be at places like this because inevitably your first several rotations you aren't that amazing-- at least I'm not. So I put places I'm really keen about last or not at all. I'm pretty happy about the way this worked out because as I'm discovering it is a slow learning curve to learn the way they want you to do your job. And even if some doc somewhere says you're really good at it, another doc at another place will say "WTF, you suck at this."  Its a little frustrating.

So in ER, the letters of rec(LOR) are not the same as they are everywhere else. Most LOR are from one doc stating how long they've known the person, and what they think they're skills are. In ER, skillz matter more than someone liking you or not. They have developed something called the 'standardized LOR' also known as SLOR.  SLORs are just a sheet with different categories of skills listed and numbers behind them.  Things like ability to handle stress, ability to think on their feet, suturing ability, where that candidate resides on your match list, etc. Its almost an evaluation. And its LOTS of pressure.

Enough about that.  So I'm not seeing super crazy stuff here. Again its not a trauma center so its just general everyday stuff.  Although, I did see this lady who was a diabetic and had high blood pressure and she was only 30.  This is her foot.  Craziest amount of edema i have ever seen.  And so you know, she was thin not obese and her foot isn't broken, its just CRAZY swollen.  I undid her bandage and stared asking over and over are you sure this doesn't hurt?  She also has and ulcer on her ankle, that has been there for 3 years. Diabetics heal slower than everyone else.  You can see her toes and how her heel sticks out more.  It was super weird. And yet neat.

I must admit there are times when people come into the ER and I wonder why we can't help out the family practice/internal med people and start them on some BP or diabetes meds. Especially when their blood pressure is over 200/110 and climbing.  It makes me a bit nervous-- i always ask if we can send them home with some meds. Maybe this is more of a family practice/internal med mentality but come on!  You can just kick them out and say good luck..... Maybe this is the difference between primary care and specialist mentality.

So since I've no special stories, I'll take this time to quickly say, in ER its all about the presentation. You have to use your presentation (which should be under 30sec) to cleverly display your knowledge. Like use your negatives to show what you are ruling out. Report only the peritent findings and be sure to only address 1 complaint. This all sounds not too hard, but in the ER is quite a skill and something I don't have yet.  Try taking a crazy patient or homeless or any weird case you got, so and so who is allergic to their roommate, was hoping to get a CT on their heart because they missed their cardiology appointment for their heart murmur, is totally out of their meds, they get beatup by their boyfriend, and are 4weeks pregnant and were hoping for an ultrasound.  SO kids what is it exactly that they are in the ER for?  Oh yeah you only get about 10 minutes while they talk to decide and then examine them because you have 8 more people to see? In someways i envy the FP/IM people. They can have their whole visit concentrating on getting all of those things done for them, but in the ER you can't. You rule out what will kill them in the next 5 min and then kick em out with a "go see your FP"

Sometimes medicine is so flawed. I feel as if no particular field has everything I want. So how do I pick the best one?  Why am I still feeling so undecided and unconfident?

ER: My first audition rotation

WOOOOOOOOOH!!! first offical ER rotation.

Since this is what I want to do this is important.  It's called an audition rotation.  Since everyone in medical school studies the same information, we have to choose what specialty or path we want to take in medicine.  And fourth year we do special rotations called 'audition rotations' where essentially we work for a month for free and they see if they like us and we see if we like them.

This first one is in a suburb hospital so its not as hardcore as it could have been, but i wanted something more low key since its my first rotation in this area. Now most people are asking how do you want to do it if you haven't been there, but the answer is easy. It all the rest of the rotations i went down to the ER to admit patients or work traumas all the time. So i've been down there alot.  And honestly, of all the types of doctors, an ER doc is the one I respect the most and would be most proud of if I could do it.  That said, i don't know if i'm particularly well-suited. But I suppose we will find out...

So I had to move states for this one month and its challenging to find my way around and find a grocery store and find places to study. I live in the hospital housing with other people and its just a two bedroom apt with bunkbeds in random places and NO INTERNET.  It's killing me slowly... :(  Luckily I found a panera but am rapidly becoming sick of panera (being i do all my studying there).

I was a little nervous but not as much as I thought I would be. I mean, it was awkward as all first days are trying to figure out where to go and what they want.  And though I feel vastly behind the other students auditioning (how do they know so much more than me?), I think my 'give-a-damn' broke and am just trying to improve over the course of my time here and learn as much as I can.  That's it.  Nothing fancy. I realize I'm not the brightest crayon in the box and tho I am envious toward them, I will be happy ultimately as long as i'm not that doctor that all the nurses say 'i would never take my family members to them.'

This is a place with a bit of smaller residency in the ER than I'm used to and its not a trauma center so they don't get the big crazy cases. I did this on purpose so i could learn the 'bread and butter' cases, the simple ones that most ERs see. We got a kid with his fingers chopped off and a few overdoses. One case I thought was an overdose but turned out to be atypical presentation of a NSTEMI (heart attack).  It was pretty interesting.

The hardest part about this rotation has been doing presentations to the docs. They don't want to hear about the case, they want to hear your differential and your plan. And I don't mean "give pain meds" or "do some imaging"  I mean they want you to know to give "4mg of zofran for nausea" and "do a upright abdominal xray because we want to look for water fluid levels to rule out small bowel obstruction."   If you order one test or have a certain differential they want to know why you are ordering that test or why you didn't order another test. They ask dosages which I know NONE.

They think i spend forever in the patients room when I actually run down one of the back halls and frantically look up things on the books in my pockets or the iphone that runs SOOO SLOW.  It never really helps me much but I try hard to organize my thoughts.  My challenge has also been including the negatives in the presentation. I can't just say rest of exam was within normal limits. I need to say no tearing back pain, no murmers and other negative finding related to specific diagnoses that I ruled out.  I had no idea 'risk factors' and criteria were so freakin important!!!  why are boards information not as helpful as i thought! Its exhausting. and i can't believe that one day i'll know all this stuff. because.... i can't possibly know it now.

And to top everything off they put me with the program director who pimps alot (asks questions in a demeanding way) about things I know nothing about.  I've been yelled at twice about not being confident enough and that i should fake it until i make it. But i don't know ANYTHING. its so frustrating. I have no idea how to change my whole personality for this one rotation.  I should have picked my rotations more carefully because i might have shot myself in the foot when it comes to getting jobs at these places.  They think i'm slow and shy and stupid.  But they also started me out on nights. So whatever.

Anesthesia: open heart

So. I got to see an open heart surgery since anesthesiologists attend all surgeries that happen in the hospital. THis one was a by-pass and a valve replacement.  By-pass surgery is complicated and can depend on the number of arteries in your heart that you have clogged.  There are 3 big arteries that feed your heart muscle-- because like a good dealer it doesn't tap into its own stash (if you know what i mean).  So all the oxygen from the heart is fed through 3 vessels. If one becomes clogged or partially obstructed you are having major problems. Women and elderly seems to have more 'atypical' chest pain.

Anyhow if your artery is clogged then we need to fix it and fast. one way is to go to the 'cath lab' directly from the ER if you are having a heart attack where they use a little mesh wire to hold the artery open-- this is called a stent and I happen to have a picture of it. However, notice that the plaque in your artery is still there. The stent simply stretches the artery so its only a bandaide. It doesn't fix your problem.  This procedure isn't what I saw however, it was just a little background.

So this surgery involved bypass of two arteries in the heart after several stents. Once a stent is placed the artery cannot be messed with in that area.  So we took the internal mammary artery (the artery that supplies your breast) and dissect it away from the tissue and then sew it to the clogged artery after the clogged region of course.  Eventually your body makes tiny vessels that keep the tissue of your anterior chest alive so there is no long term problems with the skin there.  But there are only two arteries one for each side so what if all three arteries are clogged. You can use a vein in your leg called the Saphenous vein.  The problem with this is a) its in your leg so we have to do surgery on your leg and chest b) veins have valve to prevent backflow so in order to allow proper flow we have to put the vein in upside down so the valves don't obstruct or slow the blood flow c) veins are lower pressure than arteries so to suddenly put more pressure in the vein means it can rupture easier and takes time to thicken.

That said, here is a picture of the heart valve we put in. It is a pig valve. The coolest part of this is it isn't actually the heart valve of the pig. Its a valve made out of the pericardium (the wrapping around the heart). Neat right? I took pictures of the side and front. The white cloth is taken off after it is sewed painstakingly into the heart. It is very fragile and people who have valve replacements are at an increased risk for endocarditits (a condition where blood and bacteria form clusters that cling to the valve, if the clusters get big enough it can release bacteria or small pieces through the body to infect or it can clog smaller arteries and cause problems).  Whew that was a long one.

I must say I was all up in the heart surgeon's face asking questions and pointing at things that he got flustered and asked me to back off :) ooops.  then the anesthesiologist was all jealous or something because i wasn't interested in what he was doing. It was ridiculous.  SO i spend almost four hours silent sitting on a stool that felt very reminiscent of 'time out'.  I spent most of the time watching the heart beat in this guy's chest and thinking.... besides the fact that it can beat/move on its own without the brain's imput, its not all that cool.  I mean, cardiologists are essentially the plumbers of medicine dealing with tubes, pressures and the fluids that go through them.   And despite my eager question asking, i have no interest in cardiology or surgery. I can only best explain through an analogy:  Learning to fix your kitchen sink is interesting, especially when its yours and its not working. But do I want to fix everyone's broken kitchen sink for the rest of my life?  No. Not interesting enough.

Okay one more fun fact before I have to go.  So i'm going to make you think.  IF the heart is beating in the chest and your patient requires it to do so to live, how do you do surgery, especially sewing together arteries (which is really hard) on a moving target?  Most medical people will say put them on a bypass machine which essentially is a machine that pumps and oxygenates the blood for the patient. The problem is this carries with it HUGE amounts of side effects, which i won't get into here. So if you don't use a machine, which we don't very much anymore, what can you do?  You can't stop the heart beating.... and the more your push on it the slippery-er it becomes.

So they invented this cool little tool that doesn't hold the heart down instead it has two arms in a V which suction cups on the bottom. THe surgeon places it so the artery is between the arms and then SUCKS the heart was up to him! GENIUS!  On top of all this remember the artery has blood that it has to feed to the heart muscle that is still working... and we can't clamp it off or it would be killing the muscle. SO they have to sew it with the artery still pumping blood. Yeah bet you didn't know that.  That is called some SKILLZ. what up heart surgeons!

haha. anyhow time for me to go.

Anesthesia: Behind the Curtain

There are a lot of reasons to like anesthesia. You are the only doctor in the whole hospital whose sole job it is to take away pain. If you think about it that is a really big deal. Almost everyone who comes into the hospital or goes to a doctor does so with the primary complaint of pain and as an anesthetist you take that pain away.  Maybe not forever, maybe not even for a whole day but you give the patients a reprieve from suffering. You get to touch every specialty on top of it: having a baby and in too much pain call the anesthetist, going into surgery and don't want to feel it, call the anesthetist,  having chronic back pain with no one else to turn to, call the anesthestist, having a bone put back in place and can't take the pain, call the anesthestist.  I am surprised so many overlook this specialty because they are the doctors whose patients are happiest to see them and saddest to see them leave.  And despite their bad rep of sitting in the corner and reading a magazine on the job, they are responsible for most people's whole hospital experience-- the lack of pain.  And they are the people who put in the most numbers of IVs, central lines, lumbar punctures, and other procedures. (I do love procedures).

Most of anesthesiology has revolved around giving the perfect anesthetic, which is not just pain relief but also amnestic so you don't remember any of it and sedation so you don't unconsciously hit the surgeon as he/she operates. The term we discuss for this is called MAC (minimal alveolar concentration). This is used to compare the potencies of the various gases.  The MAC is the concentration of that gas that it takes to quell 50% of people's motor response to pain (aka smacking the surgeon). This gives you a 'starting point' concentration of gas to see if the person requires more or less. There are many other numbers and calculations that have to be done to figure out the exact right amount.

Of course, despite pain medications and maxing out on gas, there is only so much that we can do. There is nothing that anyone can do to take ALL the pain of surgery away.  This is something that many patients don't seem to understand.  The limits of pain management can only be stretched so far, if patients require more we give them something to sleep because there is nothing else we can do.

An anesthetists world is an amazing amount of flashing numbers, math formulas, and pharmacology. When things are going good, they go very well and can afford to read in the corner, because only rarely does something go wrong.   There is an art to it that many were sharing with me.  For example, its long been known that redheads have fiery personalities and medically the pigment they produce is a totally different chemical than the pigment from the rest of the population. This normally doesn't apply to medical practice except in anesthesiology where apparently the amount of gas given or pain medicine injected must be altered. They are more sensitive to certain medicines and wake up faster and even fight harder against the tube. (who knew?).  Also people on Lisinopril having more liable blood pressures under anesthesia for some unknown reason- so you have to fight their pressure the whole time. There are all sorts of little weird secrets that I have learned, but none of these facts have been from the doctor..... most of my time is spent in the OR and most of that with the nurse rather than the doctor. 

Despite giving anesthesia my best effort, and despite learning as much as I can.... I must say I am still uninterested in it-- that's an understatement. It is the most lackluster, boring rotation I've been on yet. Probably because  anesthesiologists are only present to put the patient asleep and then wander off, leaving the highly trained nurse anesthetist to monitor the patient (and me to stare at the floor because i'm not allowed to help).  And most of the time, if things go well, they simply record the vitals and sit there until the surgeons are done.  And from what I have discussed with the nurses during the long long hours of sitting and staring at numbers, they love their jobs because they get to make lots of their own decisions (after all they have a masters) plus they make tons of money without any liability or malpractice (covered by the doc they work under). In some states they can work independently, working under a surgeon instead of an anesthesiologist. But all this doesn't matter because I'm sitting on stool for literally HOURS just staring at stuff. The floor. The puddle of blood and the way it splatters. The grout in the tiles and wondering how much forensic scientists could study off the residual DNA still probably embedded in the floor..... 

So besides monitoring the nurses and being there for questions.... what do the anesthesiologists do??  I am still unsure. It seems the nurses have moved in on this job. And this makes it a boring rotation, at the very least they should let me bring my study materials or my phone to do questions or SOMETHING. But they don't. Its not sterile. I go home everyday at like 2.  Most of the time I feel like its a waste of my time because I am so uninterested in this stuff its not even funny, despite being allowed to do intubations. Its not worth it in the end. I should have taken these two weeks off. To study or do something useful.  *SIGH*

Trauma Surg: last shift

SO! It turns out my shift was about 30 something hours. Which was long and the first shift where I worked that long without even a half hour of sleep.  We saw about 17 traumas in that time and it was pretty crazy. 

So the only three things we see in trauma are: falls, Motorvehicle/motorcycle accident, and assault (gunshot, stabbing, or fists)

Here are some stories.

This is a 300 pound woman who came in from a rehab facility after having surgery. Since surgery, she was confused and lethargic. She has had diarrhea for two weeks but hasn't gone in about 3 days now.  I have to shake her shoulder and repeat questions everytime and her answers aren't particularly coherent.  It was crazy because she had the biggest anterior hernia  I have ever seen and it had been repaired at least twice and was still so large it would never be fully healed unless she lost weight. Anyhow the rehab center thought she had a bowel perforation, but as you can see from the xray here, it looks more like small bowel obstruction from all the air in the bowel.  Poor lady barely fit in the xray film and didn't fit in the MRI or CT machine unless we called the zoo.

This next case is very sad. It was a 3day old baby that has air in her brain. You can see the black spot in the upper left side. Unfortunately, air in the brain is always always bad. These parents were new and left their baby unattended around the family dog. The dog treated the kid like a puppy and picked her up by her head and carried her around. When she came in her brain was visible and she was bleeding profusely. She coded twice before the parents finally let us stop.  I can't imagine what they were going through.  I could have taken picture of this one, but it seemed so irreverent. I could not, so I settled for the CT. You can see that her skull is in pieces and her brain matter looks pretty swirled. She was not going to make it.

This case was 2 people on a motorcycle who were hit by a car. It was interesting because both the man and his wife ended up with almost the exact same injuries except the male's were worse. The couple was engaged and they were freakin out! She didn't want their clothes cut off and he was just trying to not scream. His bones were open and sticking out of his leg.  He broke every bone in his knee. I did get a crap picture of the bone sticking out and the xray of the knee. That way you could see what was under.  In Motorcycle vs. Car accidents, its always worst when its the car that hits the motorcycle.  This particular injury is caused in a complex mechanism. First the pressure of the car rolling on top of the knee breaks the femur then as the leg twists from the weight of the car and the body of the person does not, the two lower bones are torqued enough that they twist and break. In this xray you can see two white bars, these are the cards we put under broken bones. So don't get confused by them :)  Later the ortho guys took this guy to surgery and pinned basically every bone in the whole knee.  It was quite the process.

Hmm... There were three gun shots this night. All three gave the same story, which we all know was a lie. "I was walking through the field/street/store/house all by myself minding my own business when suddenly some guys ran/drove by and I heard shots."  Nobody is ever walking by themselves when they get shot.  One kid was shot through the neck, one through the chest, and one through the ankle. Then we found a hole in the pants of the ankle kid- so obviously he shot himself. Pft boys thinking guns are fun. Ridiculous.

Let's see another story was of some drunk dude who fell off a roof. Of course, he didn't believe he was sick or hurt. So he pulled off his collar. This is obviously not a good idea. He left the ER and then of course the xray came back. He has a crush fracture of his c7 vertebrae. So hope he doesn't die/go paralyzed, which he most likely will.  Great right?

Also, another drunk guy came in, unconscious and shoring like a banshee. He wouldn't wake up and he had dried blood all over his face and we were guessing that maybe he had a jaw fracture. Witnesses said he had hit his head when he fell, apparently hit the curb.  But before we could do anything his heart rate dropped, he quit breathing and we intubated. It was quite fast and we couldn't get tube in and I was sitting there holding his neck for the residents and thinking, shit this guy is going to die. And then they got it and gave him some good old atropine and he came back.  I have to say, I wish i could be there when he woke up and tell him how fucking close he was to dying on that table because he thought drinking and fighting were cool. But then again, his tox screen will probably come back with more than just alcohol. I wonder what it was like to know that you almost died.  I almost think it worth it to videotape that stuff so they could see how bad they were in trouble.  The sad thing is, i know it wouldn't change any of their choices.

Whelp, that's it for trauma i guess. There is really nothing you can say or do to teach/talk most people out of their stupidity. Even the ones that change eventually go back. Its hard to feel the thrill of excitement about saving someone's life when you know they don't much care for that life anyhow.  I think this is why I can't dedicate myself to trauma. Its why I want to do ER where every once a shift or so you actually get someone who genuinely WANTS your help. Not for drugs, Not to continue bad choices.  Maybe this is why I can stand the psych cases who just want medical attention....  Something to ponder for later.

Trauma Surg: Pieces of a whole

So last week in trauma. So bittersweet. My last night will be a 24 hour whooh! goin' out with style. also sleep deprivation and a very lonely puppy :(

Another fun observation: If there are a group of doctors on an elevator, everyone lines up evenly against the wall. I didn't notice this peculiarity until I found myself starting to conform. Why do i need to lean against the wall in an evenly spaced pattern?  Also why do i instinctively follow people off the elevator when they are not my resident? (haha, med students are required to follow residents everywhere. And it just becomes part of second nature. Tho that's a bit embarrassing to admit.) 

As for realizations, there are many new things I've learned about myself and medicine.  I got into medicine for so many complicated reasons, many that I don't understand or can't express myself.  But I do know that in many ways I entered into medicine for the challenge to push myself to find my limit. And with 4th year starting next week, i have to say I have been more than adequately challenged, mentally, physically and emotionally. And it wasn't what expected, it didn't push me to the edge in a way I thought it would. Whole new edge people. It was very anticlimatic. And I know it wasn't my limit because we are always capable of more. More hours. More studying. More discipline. More effort. Its hard to get used to and its hard to admit that you haven't done all you could.

This above random image is brought to you by an aortic root rupture (the main vessel coming out of your heart that is bleeding out so fast it looks like its exploding) from a person who hit their steering wheel so hard it actually separated the heart from the vessels. Talk about a sad ending for the patient who did not live, but a really awesome CT.

Anyway, many of the stories we get in trauma are only pieces of the full stories. Trauma itself is very anticlimatic because you don't get to know the endings and sometimes even the beginnings (like how it happened or why or even what happened afterward). I find this frustrating sometimes because patient stories is what I really live for. And it makes me fear that one day I might get tired of all these adventures. One day my job that I have invested in so much, will become just another job to me. This thought sucks and it makes me apprehensive that ER is the place for me. If I no longer cared about the story, I don't think I would like it any longer.  Good news is for now.... I am still enthralled! Which makes for a better blog for you. So on with it!



I am kicking myself for not taking more pictures this rotation, because i've seen some really amazing things, but in the heat of the moment you don't think about your camera until its too late.

As is the case with this awesome tongue laceration. This is a 19y.o. drunk guy who came having bit straight through his tongue (and smashed several teeth). The amount of blood was so copious that he was having trouble maintaining his airway. Not only was he swallowing it, it was gushing from his mouth in little pulsitile spurts all over his clothes, yours, the ceiling, whatever.
Tho your tongue is not the strongest nor most vascular muscle in your body, it is on the top three. And it is probably the most used. And when something is bleeding so fast you cannot even see the wound itself, its probably time to admit. We gave him suction, debated intubating... and hoped it would clot. When it didn't after 8 hours, they pulled a bunch of strings and used about 5 residents and 3 medical students to suture it. The inner muscle of the tongue started herniating out, looking like very bloody ground hamburger. I was only able to take a picture after we finally sewed it. I am constantly surprised by how good these horrible wounds look after suturing. In this picture you can still see some of the herniation of the tongue muscles, but it doesn't look so bad as it did before. I wish i would have thought of a before picture.

Another interesting random happenstance, a drunk lesbian girl who got into a car because drinking and driving is ALWAYS a good idea and crashed. She 'degloved' her knee. This is a particularly apt medical term because the injury peeled back her skin over her knee so much that all that was left was the bone. So she had a flap of muscle, skin, and fat that just hung there. It was somewhat how I imagine scalping someone would be only at the knee. This is a pretty serious injury but luckily my resident was tired and had more important things to do. So i got to sew it back up. It only took me 3 hours! Despite looking nice and pretty in this picture (yeah check out my skillz!), it was a giant mess. Again no before picture. Most of the stitches were underneath the skin. I had to sew all the muscles back to their avulsed tendons and even got to sew a tiny lac up in the artery. And wha... la.... a pretty neat scar and a fancy new knee.  Now you may wonder how exactly I knew she was a lesbian, so let's just say that during this 3 hour and approx 32 stitches job, she decided in her drunk wisdom to give me a full evaluation of all my physical features: the best and the worst. This was nothing if not incredibly awkward and tried as i might, i could not get her to stop. And I neither could my resident who could only bear to listen to about a minute before he became too embarrassed to stay. So yeah. Fun times.... or something.

More to come.