Neuro: punked

So I've been punked. My very first day. By the ER residents. I was just minding my business doing rounds when they asked me for help. Ironically, it was thanks to my MRI skillz that got me into trouble.

The ER residents know me now, I think they all might talk about how annoying it is that I hang around so much, but you know. At least they know me. Anyhow, they asked me to come over and read this MRI with them.   They point out this is a female patient with pain. They point to the bottom of the screen and say this is the tibia (pure white triangle upside down) and the thing above it (circle) is the knee cap (big white circle)... what is wrong with the knee surface? And there are some grey swirls in the top circle.  I start trying to guess, cartiledge changes? Fracture? No way its a fracture, what they heck is that? Foreign body? Is that a quarter in the knee?

At this point they are peeing their pants laughing (like i'm pretty sure i saw some darkening of the pants) and I am just ignorantly guessing thinking, Man i am like the worlds worst MRI-reader.  And finally they say, that's a baby.  That's totally not the knee. And I am looking all sheepish and all oh, i totally knew that. (ha. good cover, right).

Now, I'm sure you're thinking I'm going to be the world's worst doctor. But these images are remarkably similiar if you get just 1 picture.  To demonstrate how ridiculously similiar these images are I went to google. However, my image was a lot less obvious. You have to use your imagination, and a lot less arrow signs.  Again, these images (unlike the rest of them on my blog) are from GOOGLE. Not actually my images.

So turns out prego women get MRI's all the time for appendicitis. And no problems with the baby.  However, I guess this 'baby in the knee' on MRI is a big funny joke they do to all the new interns. So I guess they felt like I needed to be broken in.... maybe i'm making an impression after all?

Gen Surg: Final Thoughts

So Surgery is over. And I don't have anything new to say that I haven't already said. In the end, I liked it. The surgery part was interesting. I imagine doing it everyday would be rewarding.  However, the lifestyle is too much for me. The bottom line is at the end of the day I am NOT willing to give up all of my chances at a personal life....or a family. I just don't love it enough. I don't think I love anything that much.... Plus, I learned from this rotation that I value sleep too much.  And that there are many jobs that are beyond me and this is one of them.

The dedication you surgeons have to your profession is unbelievable. Yet, I must say I'm a bit relieved its over. Now on to Neurology.

Gen Surg: Radiology lessons

So check it out- radiology at my school was somewhat... subpar. So I have been saving certain characteristic or obvious CTs and xrays to help me learn. And trust me, when you're scrolling through half a dozen CTs, MRIs, and xrays full of shades of grey every couple hours these aren't so easy to pick out. So here are a few of the images and there answers (i've kindly added the 'arrow sign') below (don't cheat!) So here is a radiology lesson of the past monthish of patients, see if you can find the defect.

Here is a general xrays of a patient who had a collapsed lung (pneumothorax). You might be familiar with this condition because TV shows glamorize this condition (when the doc stabs someone in the chest with a needle and suddenly they can breath again). For the most part, the TV treatment is true but generally something has to HAPPEN to your lung for it to collapse (aka car accident, lung CA or disease, emphysema, etc), it doesn't just happen in the middle of a restaurant...usually. And unlike they show on TV if its less than 10% of the lung (as both of these are) and if the patient is not symptomatic, we don't  stab anyone with anything. You body will reabsorb it on its own without any problems. (i know.... so much less fantastic than TV).

Crash Course for beginners: a CT scan (also known as a CAT scan) is probably one of the most useful scans done in the hospital. It is a 2d picture of your insides, showing your docs what's going on inside. Typically, they are loaded on a computer for doctors to scroll through some 200 images are taken every millimeter of your body. It starts at your feet and works it way up to your head. They are done at different angles depending on what the doctor wants, but ususally they are done with the patient laying down.

This patient is a person who was in a MVC (motor vehicle collision) we also call it car vs. pole.  He had some abdominal pain and a quickly dropping H&H (hemoglobin and hematocrit). We got the CT and immediately called the trauma team. You can see how the blood is pooling by the liver (the liver bleeds fast!)

This is an elderly (88yo) woman who was incontinent and who often had UTIs. Everyone just assumed she was old. Then due to an incidental finding by an ER doc and a bunch of workups later we found this. A hole between two different organs is called a fistula Poor Poor woman.  She has a hole between her anus and vagina and then vagina and bladder.  So if you can imagine... she has poo coming out not only her vagina but also poo in her bladder.

Here is an easy picture that hopefully anybody can see. Blood in the lungs, we call it hemothorax.

It is very important to look at the CT a couple of times because oftentimes you find other things you wouldn't have normally seen. Below are some images of the above patients who had some very cool incidental findings. The first one is calcifications of the aorta.

Well hopefully that was enlightening :) Fun pictures definitely. Interesting if nothing else. Til next time.

Gen Surg: 'official'

So i was told I am now an official medical worker.

There was a 40 y.o. M who had a bowel exploratory surgery. He was in good shape and quite the organic food lover. I had checked up on him every morning for about 4 days so we had some report. His diagnosis was Crohns. Anyway, He had a huge line of staples maybe about 50 because his incision went from sternum edge (xyphoid process) down to the pubic bone. Anyhow, they wanted me to remove them so he could go home and I wanted to do a good job. The attending left and I went very slow to make sure they didn't hurt him (no pain meds). So as I take them out one by one, I ended up sitting on the bed and leaning over to intently pull out these staples. And about oh 4 staples to go at the bottom, I realize.... there is this hard object poking my elbow..... in his pants.... wait a minute! It was all suddenly awkward and i pulled the last staples out really quick. Then I  basically bolted out of the room. (talk about not handling that situation with grace....) So yeah. Gave my first boner to a patient. Not awkward at all, especially because the nurse saw the whole thing. And she just laughed at me, no warning nothing, just laughed silently in the corner!!

All the MALE surgery residents heard about it and thought it was the funniest thing ever. Obviously, I never heard the end of it.... *Sigh*  at least I know to pay more attention to the patient and less to the staples....

gen surg: textbook case

Here is another couple of cases. This 58y.o. male presented with some rectal bleeding and constipation. He had no fever, no white blood count but some 10 pound weight drop in the last couple weeks. Below is the actual imaging results. There is barium enema and it shows as I added to the xray below-- what we call an apple core lesion. You can see how the barium (white color)  narrows in part of the colon- it narrows to the size of an apple core because there is a tumor that is blocking most of the lumen.  This is usually a sure fire sign of colon cancer. It was strange to see this on the computer because its basically right out of our text books. You should also notice in the right upper part of the picture the obvious loops of bowel that are full of air. This is called "ladder rungs" and it indicated an intestinal tract obstruction (probably caused because the poo can't pass the cancer. We took him to surgery the next day, took out the part that was full of tumor and he is doing well, cancer free.

        

Gen Surg: Quickie Update

Okay so I have a few pics that I gotta post else I'll forget. But thus far, surgery really picked up this last week. All the residents took their in-service exams (specialty specific) and now they mean business. So if it was even possible,  I am even busier than I was before. Now I'm following them to different hospitals, answering consults on my own, and even witnessing political pissing contests between surgeons. I spent a 'short' day on saturday that was as the resident proclaimed it gunna be 'quick and easy.'  And of course I was there for 14 HOURS!! Without lunch. I had a fig newton as dinner. And about 4 cups of coffee. More later.


So about oh 40% of general surgery cases have to do with the gallbladder. There is at least one every other day. SO i might as well document a couple. Usually you get your gallbladder out because you have gall stones or an infection. In the surgery world, most gallbladder removals (cholecystectomy) are done laparoscopically. Thus we call them a 'lap chole' (lap kohl-ie).  WE put in four tiny inch wide incision in the belly then blow up the belly with CO2 gas. Put in something called a port where we can hold open the hole for our long instruments and peel the gallbladder off the liver. Because this surgery is so common, most surgeons keep a log of how long it takes them on average to do a lape chole. This number is what they compare to others to find out if their skills are good, bad or average. Weird I know.  But they don't really have their eye on the clock, at least none of the surgeons i've seen do. The nurses keep track for them. Below is a picture I took of one of my patient's gall bladder's filled with stones, these stones are made of cholesterol. (don't eat at McDonald's kids).

 

Next case is probably best patient of the year. Guy comes in to ER, who has a PEG tube. Its a little hole in your abdomen that has a tube in it so we can feed you without putting food in your mouth. This is usually done for someone who is having trouble swallowing or who is in a coma and can't be eating.  This PEG was in a guy who had suffered a anoxic brain injury from a car crash. He was mentally not with it and he pulled out his PEG tube and ATE IT.  Yeah that's right. He ate his own PEG tube. :D   We crazy docs thought this was just hilariously ironic. We gave him another one and admitted him to the hospital where he pooped it out without a problem. Weird thing is he can totally understand you and follow commands, he just has to be restrained. It should also be mentioned that he ate chunks out of the blanket in the ER, grinds his teeth together (its painful you can tell because of the sound) and constantly licked his arms. This is where several med students and I came up with the phrase "you can lick your arm if you wanna."  which is applicable to any patient who does something stupid but they do it anyway. I think its catching on...   Below is a picture of his PEG tube. Nothing special. 

Gen Surg: Bowel Perf - EDIT

Hey, I added this late. I realize. But hey surgery schedule is crazy.  Anyhow remember that gen surg is all about bowel. And there are lots of bowel surgeries. Why wouldn't there be being that your abdomen is full of it. If you want to know what it feels like imagine a rope of warm Jello and it is the thickness of your eyelid.  Go ahead a just try to hold it... good luck.  And you can totally feel the poo move through it, though the bowel doesn't like to be touched so it generally stops moving the poo when you touch it. Medically, whenever the bowel is touched there is a huge possibility of something called 'adhesions.'  Adhesions are tiny threads of tissue that are kinda like scar tissue that are very strong and can cause bowel obstruction and chronic pain. Adhesions are the #1 most common side effect of any abdominal surgery.

 You should also know that there are tiny 'tags' of fat that hang off the bowel. This is true for everyone, but the more fat that a person stores the more 'tags' there are on the bowel. These tags are the most variable area-- and function for a little bit of protection for those easy to rip bowels.

Lastly, the bowel is divided into different parts. Small intestine: duodenum, jejunem, and Ileum.  Large intestine: colon, sigmoid, rectum. The small intestine does most of the absorption. The large intestine absorbs mostly water. There is lots of bacteria in your bowel, but the most importantest are in the colon because they can make vitamins like B12 and they make gas when they breakdown (cough cough farts).

Anyhow, these pictures are of a bowel perforation, but not via trauma or other surgeons. It was from straining too hard when he POOPED. Yeah, bet you'll never think about pooping the same way. haha. ah, the terrors of life. :)  Anyhow, Bowel perforation is a big deal for a bunch of reasons. 

•  The first is it is leaking all of the digestive materials into your abdomen = gross.  Bowel perforations when you open the belly don't just smell like ordinary poo (ordinary poo goes through the colon which dries it out and all the nutrients are already gone). It smells unlike anything you've ever smelt before. And its awful.   
• Next, all the bacteria in our food plus the bacteria that helps us digest our food leaks into the bowel. Causing fever, infection, sometimes abscesses, or other major problems. 
• Lastly it won't heal itself. So it can be life-threatening. 

So...  this hole is in the colon. You can see in the picture to the right, i put the tools pointing at the hole.  You can also see the appendix dangling off the left part. The green above the hole means that the bowel contents (the poop) has already been in the abdomen long enough to stain the outside of the bowel. 

Why is it green?  Green is the color of bile. Bile is made in the liver and stored in the gall bladder. Bile helps us digest fats. As the poo material goes through the bowel different enzymes are added until eventually it breaksdown or gets reabsorbed to become brown. Ta duh! Lesson of the day.

Check out this close up of the perforation....

Gen Surg: Typical Day & thoughts.

So again, I thought that surgery would be more hardcore. I mean don't get me wrong I'm not a genius or even close to rocking this rotation (especially considering this one resident who constantly gives me this smile i'm sure means 'you have no idea what your talking about you idiot' and then ignores whatever i said).  But surgery is just...underwhelming. Here is my typical day thus far:

• Arrive at 4:30am or 5:00am (depending on how many patients I have)
• Round on all my post-op pts (involves waking them up and doing a SOAP on everyone, labs, etc)
• Meet with Resident at 7am to round with them, and you better know your patients new stuff...
• Sometimes there is a lull after rounds where i can snag breakfast and study for an hour, most days not
• Visit patients in pre-op and write pre-op notes at least 1 hour before their surgery
• Scrub in and enter 'sterile zone' where have to wear cafeteria lady-like hat, mask and booties.
• Wait for surgeon/patient/resident to arrive, surgery to start, room to be cleaned, etc
• Watch scheduled surgeries (hope you've read on em the night before). Since there are so many students I only scrub in on 1 a day (scrub in means potential for me to actually do something like hold a retractor)  The rest of the surgeries I stand on a stool looking over somebody's shoulder. If i'm lucky I can see what they're doing. Most of the time not. Also if its a good day the surgeon will ask me questions and think i'm stupid when i don't know the answer. But most of the time I have to stand still for 5-8 hours at a time on a stool quietly and I sneak practice my surgery 'ties' with the 3.0 vicryl suture i stole and sewed my scrub pants. (you can leave it there all day and nobody notices).
• Answer consult pages for entire hospital for gen surg
• Round with the attending- more just getting approval for what we've decided to do- lots more pimping (asking questions in a derogatory way).

Then i can go home. Sometimes its as early as 3pm other times it's 10pm. If i'm super lucky, the other med students and I have worked out a system where we cover for someone while they 'had to resterilize' aka- go grab some lunch and granola bars for all of us. I have never gotten a chance to get dinner, because if its a long day- residents and surgeons are cranky.

I don't mind the hours. And I don't mind being busy or not knowing the answer. I just hate all the WAITING. I hate standing on stools and looking at nothing. I hate the attitudes of most of the surgeons I encounter- tho it's really not as bad as TV says. I am surprised to say it, but despite LOVING anatomy and despite LIVING for procedures.... surgery sucks.  I don't want to do it --even a little bit.

Weird. I expected surgery to steal my heart and I was scared with all my procedure and anatomy love I was going to have to talk myself out of surgery because of the horrible hours. But no, I don't even have to talk about surgery at all. I already dread my last rotation-- trauma surgery.  At least I'll be down in the ER most of the time. I guess we'll see if anything picks up or not.

Gen Surg: the Ghandi of Surgeons...& other adventures

So I think its worth it to discuss my attending surgeon, who is a woman, because she leaves quite an impression.

I got lucky to be on her service because of her attitude and overall personality.  She is in many ways the Ghandi of all surgeons. She never yells, screams or throws tantrums. She likes teaching. She never takes her frustration out on others, i've never seen her raise her voice or get frantic. Her version of panic is a furrowed brow and a "well dang it, the patient is fighting me." She is someone who walks into the room subtly without an ego, but everyone eventually notices she's brilliant. Not a genius, just right most of the time. She is someone who I can't help to admire. If i had to describe her in a single word, it would be poise. I would say she is someone I respect and represents true elegance.

You have to remember she was trained when surgeon was still a world of men only. They threw scapels and tantrums and are overly aggressive, brash and sexually inappropriate. She is under incredible amounts of pressure and just lets it wash over her. She is someone who, i would imagine, would smile if she was being yelled at.  She has an air of femininity despite this environment. She always wears her hair clipped up in twist on her head. Her hair is thinning but still brown. She wears only a thin line of eyeliner on the top lid and a minimal amount of mascera. She has obvious smiling eye wrinkles and she always wears small dangly earrings. She is in all her elegance, beautiful. She aged gracefully and she has a subtle strength about her. She was told by a patient today "you're too pretty to be a surgeon," and for some reason I thought-- maybe she is.  She told me when i asked her about the lifestyle that she knew she had to make a choice: marriage or surgery. And she chose surgery, and not for lack of opportunity of the latter. Talk about impressive commitment.

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I also have to take the time to document my other adventure/realization today. Its sorta embarrassing but I feel I have to share. I almost vomited/fainted today. I scrubbed in on a tracheostomy (the placement of ventilation tube in the trachea above the sternum). It wasn't bloody or a particularly gross surgery. It wasn't even my first surgery. I just noticed very suddenly the smell of the burning flesh when they cauterized the wound, and became very aware of how tight my sterile gloves were. I noticed it was almost unbearably hot in the room and I became horribly nauseous. I looked everywhere else, at the clock, started a convo with the scrub nurse, just anything to push through and make it pass.  Then i noticed the edges of my vision getting black and I immediately backed up, just like they taught us. And the nurse said, "i thought you looked pale, take off your gown and get out of the OR."  And that's what I did. I ripped off my gown and went out to the scrub room where I hovered over the trash can sure that I was going to solidify my humiliation and puke.

Good news is I didn't.  And eventually I felt like I could breathe safely again.  The residents came out eventually and laughed. He took me to the cafeteria where he bought me some breakfast and told me the story of how he passed out flat on his face during a bone marrow biopsy and they weren't even in the OR.  He said it happens to everyone at least once and it doesn't mean anything at all.  :)  I was very relieved. We spent the rest of the day exchanging stories will all the OR techs, nurses, and surgeons about when they fainted or vomited.  It actually turned out to be a pretty cool day.

Gen Surg: 2 impressive surgeries

Surg 1-  So there was a very cool surgery that several residents and other medical students were lined up for, but since we were on service with the prime surgeon we got first dibs. Its called a Roux-en-Y. It is a very cool and relatively rare surgery (not a whipple but you know).  Anyhow I've included a picture so you can understand what was done.  The cool part of this surgery is that they open the entire abdomen (this is very rare these days with all the laproscopy) so we get a firsthand view of the bowels. And though it means standing on a stool for 5 hours, you can actually see something.   Now you might be asking why they did this surgery and I'll just give you the basics. The patient is a woman in her 40s and she has the worst reflux you've ever seen. She is dependent on PPIs to keep her from vomiting up all her food. Anyhow, they connect part of the small intestine to the esophagus. The surgeons leave the duodenum and stomach connected so the digestive enzymes can continue to used (we don't want to touch the pancreas if we can avoid it).

    

Surg 2- I was pulled out of the first surgery by a plastic surgeon who didn't have his own residents or students to help suture. I jumped at the chance. It was a breast reconstruction for a woman who had a mastectomy because of breast cancer. It was a brilliant surgery actually. He cut a 5 inch oval of tissue out of her back both tissue and muscle, he dissected the everything but 1 side (with the artery) and then created a tunnel through the armpit and pushed the back flap through it and filled the cut in her chest with it. It looked a lot like the picture above. It was like a real breast almost, minus the nipple. It was so clever and simple. Talk about cool. The sad thing is I never got to suture.

Gen Surg: My first Day

So, wasn't quite sure what to expect as always. But for some reason I was more apprehensive about this rotation than others.  However, it wasn't too bad.  Since its so close to the holiday, there were very few people signing up for surgery (as you can imagine).  The patient list was light and the residents has this apprehensive, suspicious air about the patients because this new years eve was so lacking in any traumas that they were sure something horrible was going to happen in the next couple days.

So i got a pretty good tour and learned all the weird things about surgery that nobody ever talks about. Where on your body you are sterile in surgery, how to not itch your nose, how to cough or sneeze when in the OR, when to have protective gear on, how only the surgical scrubs are allowed in the OR, etc. At least they had time to teach me, because I would have messed up at least all of that if they hadn't :).

Also I discovered why the surgery residents are nowhere to be found even on slow days. They have a SWEET call room. Its got couches, real food, and a wall sized flat screen with an xbox and about 20 games. We played call of duty for at least an hour today because it was so slow (course we can't eat tho-- not allowed out of the call room). They got particularly mad at one of the african residents who was quite the n00b. They gave it to me and took bets to see if i could do better than him. I just didn't mention I have an xbox of my own and my 34 kills per level i think made them feel bad :S. I didn't even think i was particularly good. So lesson one of surgery: don't beat the residents in call of duty.

That said, it was a great first day. I saw my first surgery-- an anal dilatation on a 17 year old female which Crohn's disease. She had multiple anal fistulas and needed to be able to poo out the proper hole.  Seeing this simple procedure made me appreciate that I don't have to get this done. ever.  She has to do it every 2 weeks.  Lesson two of surgery: appreciate the poo.

 I did get to see a couple gunshot wounds, nothing like a gun fight when its snowing. The 23 yr old got shot in the crotch, twice.  Missed his special parts by an inch. that's just ridiculous. what's even more ridiculous is that guy comes in with gunshot to the crotch and doesn't go to surgery. Doesn't have any bad side effects at all. :S  Lucky for him, unlucky for me.

They decided to let the medical students go home early (at like 3). But because it was so early I decided to catch up with a resident friend of mine who was on trauma surgery. She decided that an anal dilation was unacceptable as my only surgery and got me on a jaw reconstruction case, which was nice. But she didn't really ask.  So i had to wait until 6 for the surgery to start. Lucky for me, I decided to take an hour nap because we weren't done with the surgery until 9.  The surgery was cool, but we were just wiring his jaw shut, it was a maxilofacial surgeon who works at night, so he usually doesn't have students or residents. He was thrilled to have me. He was pushing for me to stay for the next surgery and kept throwing phrases like "see one, do one." and "if you stay I'll let you do this surgery."  It was hard to say no, but remember I got to the hospital at 5am. I still haven't eaten lunch or dinner (now i'm not hungry).  Plus I have a tracheostomy tomorrow that I have to research and a two handed tie that my school never bothered to actually teach me.  So I did the thing all the books and advice people tell you not to, I said no.  I have to go home.  Lesson three of surgery: go home when you get the chance, no questions asked.

I just hope that won't come back to bite me later.