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.

Trauma Surgery: "it'll never happen to me"

This week's stories are full of people who honestly believed "it'll never happen to me." And the most memorable one I should share is the one about me, one i've been struggling with for awhile.

It's interesting how the trauma surgeon attendings are the most callous, jaded, no-nonsense people i've ever met. They will tell you exactly what they think about any topic and trust me they have opinions on EVERYTHING. I have never felt my self worth wane as much as it has this year, this rotation with these attendings, these residents.  That said the most jaded attendings, the ones who don't really care about the patients, are the ones with some of the most insightful comments into understanding patients, situations and my skills.  They see past the bullshit. They make it so obvious and they are teaching me the most about medicine, people and myself. I think that is why I take their comments so hard, because no matter how hard I try, I begrudgingly respect them.

And Its hard to be berrated beyond what you deserve for getting questions wrong, its happened on every surgical rotation I've experienced and i've seen it happen to other students.  But its hardest to be given a quiet, condesending smile, a quick scoff and then abruptly dismissed, because you know then that your answer, your thought process and yes, even your self worth is so disgustingly wrong that they won't even bother berrating you. They quit listening to my comments, quit answering my questions, and being to pawn me off to other residents while I'm standing right there. "No, you take her, I'll take him" "What? No way. I want him, YOU take HER." It is this 'silent diregard' that degrades me the most, especially when other students are paid attention to and while still being berrated are being taught in these surgeons own special loving way. I feel left out and often feel as if I shouldn't have shown up that day, then wonder how I get stuck with the 17 hour shifts. I never thought it would happen to me but somehow, my self worth has started to hang on these surgeon's opinions. And it SUCKS because i have no idea how to handle this.


ha. anyhow. sort of awkward. So on to other stories. The first, well, is a case I have been expecting since my very first day. As it inevitably does in all ER's, it was the 45y.o. M who comes in to the ER with a 'forgeign body' in his rectum that he 'obviously' fell on.  Yes, that's right.  This is his xray. Now you might ask, why was trauma consulted, which is a great question. Its because not just multiple ER docs but also the surgery residents and surgery attendings had tried everything to get this object out of this man's rectum and failed, but also because they had called down ob/gyn (think about it large objects out of small holes) who also failed.  So who you gunna call? Trauma. By the time we get down there everyone is sitting around a big blue bucket with a portable white board making tallies. There is candy, snacks, pop, and even cash in this bucket, because everyone in the ER had bets about what exactly this thing was. So we go in and spend about a good hour, realizing we can touch it but it just won't come out. We debate surgery, which usually happens if it is this difficult to get out, but because of where it was in the rectum and his other medical issues we were unable to consider that option. So we decide to tag team it.  One person holds the butt cheeks back, the other the rectum open. The other person pushes his knees up to his chest and holds them (this is very painful and there is quite a bit of blood). The last person grabs the object with two pilers and pulls. And after a very labored extensive Mcgyver manuver, we get it out.  It turns out to have a condom over it (yeah... fell on it... right) and its a giant.... wait for it!.... dog chew toy.   Yeah.  Freakin weird.  The pot ended up going to the 'regular plastic household item' person. Anyhow, we were pretty sure that he perforated his rectum with all the tugging and blood but he absolutely refused to stay. He signed an AMA form (against medical advice) and stormed out. Guess embarrassment took over.  So the residents decided that they were going to invent a line of sex toys with handles on them, so we didn't have to pull them out so traumatically.

The next story is a little more tragic. A young woman was walking around in the dark in her basement trying to go down the steps and fell. She knew immediately something was wrong and had to scream until her husband got home from work. She was not able to feel anything below the nipple line and could not move her legs. This is her CT. It shows a complete fracture of the spinal cord that pushes into the spine. This woman is now a paraplegic, she will never be able to move her legs or feel her stomach, or pee by herself. She was surprisingly together and unharmed except she happened to fall in exactly the right place in exactly the right way to snap it. I never met the husband who called 911 for her, but i cannot imagine what he's going to have to go through now. She'll be in a nursing home most likely for the rest of her very long life.  When asked why she was trying to go down the stairs without the light on, she says she's done it a million times and just never thought twice about it. You can see from the full spine how awkwardly bent it is and you can see from the close up how one whole vertebra is missing and pushing into the cord! Bad news.

We also had a guy who needed a shower, was very thin and who had 13 abscesses on his buttocks. 13! And I guess he sorta had some pain there but never really thought much about it. And it was ridiculous. The pus was starting to push on his rectum and cause him problems while pooping, which is why he came in.  But these abscesses were such a problem because they kept healing up instead of draining that we used a skin punch biopsy (probably the size of a pencil) to cut open holes in his skin so they would drain.  And of course later it came out that he did a few 'iv drugs' but he never thought that anything like this would ever happen to him.

So moral of the story. If you think it won't happen to you, you're fooling yourself. Wear you seatbelts, don't do drugs and use your BRAINS.  For those of you who don't, thanks for the job security.