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.

Trauma Surgery: first week

Phew. So trauma surgery. Whew. Yeah. So its better than general surgery but its not.....surgical. Its a crazy mix of IM & ER.   ER part comes from dealing with the traumas. But when we get a trauma but we don't just stop there. Trauma service manages patients for days until they get discharged from the hospital. We even have trauma clinic where those patients follow up even after leaving the hospital.

So that said, traumas are surprisingly simple, if you can get over the frantic, bloody, crowded, chaotic atmosphere. Because the truth is there are only so many things that can kill you in the next 5 minutes. And trauma's job is to make sure those things are identified as quickly as possible.  Broken bones, lacerations, bleeding, pain are not even on the radar for trauma. The one and only job is to make sure you stay alive for the next 5 minutes even if it means hurting the patient (aka no pain meds, yanking on broken bones, always checking rectal tone).  Standard procedure involves cutting off your clothes, do a trauma series (aka CT head, neck,chest, abdomen, pelvis) and stat chest xrays, 50 very personal questions, exams of every part of your body, including rectal exams on everyone, checking pulses, listeinng to heart and lung sounds, and more in under 60 seconds. To be a real trauma center, we must have all these things done (by multiple people) in literally under 75 seconds. It def helps to increase the frantic atmosphere. It is hard to not constantly feel like you are in the way. It also makes it hard to help if you don't know what to do or exactly how to do it, while staying out of everyone else's way.

Despite the word 'trauma', the service is disappointingly devoid of blood and guts. We've only really had about 1 trauma per day. It seems to be primarily consults when patients turn critical or other services won't admit.  Its frustrating because oftentimes, we are just babysitting a patient for neurosurgery because they do not admit their own patients. To top it off, trauma surgeons must stay licensed in general surgery which requires 'typical' procedures like a PEG tube, placing a trach, taking out an appendix, etc.  So for 1 week of each month we take 'surgery call' so whenever surgery needs to be consulted, they call trauma instead.

When there are traumas they are classified in 3 levels of trauma in order: consults, priority, alert. Alerts are rare, but if they come, you run. So here are some patients, to better explain this.

CONSULTS

An older gentleman shows up at the ER (war veteran- predictable right?) because of a fall 2 days ago. He thought it would be okay, but despite extreme bruising on his shoulder(craziest bruise i've seen yet), he let it go a few more days.  And soon it was 2 weeks later and he admits to not moving his right arm since the fall. And he is profusely uncomfortable that he had to come in at all. He is apologizing and promising he's not a wuss but he is extremely tender and said something might be "grinding around in there." And then of course we get this xray back. Yeah. That's CRAZY broken.

PRIORITY

This was a 21y.o. male who was in a MVC (motor vehicle collision) he was a backseat passenger where he was ejected. The car rolled over him. The driver, his girlfriend, was fine because she was wearing her seatbelt. He arrived at the hospital awake but on a backboard and cervical collar. There was blood in lots of places from a scalp wound as far as we could tell. He had a tibial fracture and back pain. We put in a foley catheter (for urine) and he starts getting upset because he can't feel it.  Then we roll him over (per protocol) and do a rectal exam, which reveals gross blood and no rectal tone. He starts screaming and finally we figure out he can't feel it. We do xray and CTs and find something strange: a completely isolated, shattered L1 vertebral fracture.  If you look up at this close up I provided you can see some pieces that are pushing on the cord. This is bad. So we try to calm him down because the cord itself isn't broken, its just being pushed on.  I rounded on him this week, because obviously this is a trauma case we admitted for.  Its important that I mention that he can move his legs and walk fine, despite his broken ankle.

So I walk in his room to find out how he's feeling and he's laying in his hospital bed sleeping (cuz its 5am) and there is a woman in his bed who is spooning him and rubbing his chest. I am a little shocked, is this his girlfriend?  Didn't he just ask me for my number in the trauma bay? I go ahead and waken him up and do the exam and whatnot and discover this is his MOTHER.  Weird. Then i get in trouble at rounds because i didn't think to ask him about his genital sensation and his function. So i return over the next several hours and have to ask him in front of oh, maybe 6 people who are his friends and family if he's had sensations or erections. He says he doesn't know, would i look for him....  and now i don't know if he's flirting or actually scared to look. Um, way to go bioethics for not preparing me for this dilemma. anyhow, i choose not to look obviously.  But i get chewed out during rounds for not being able to answer all the attendings questions, but half of the residents are laughing.  And I'm seriously confused about what i'm actually expected to do medically.  I mean I've seen plenty of penises, but rarely in front of family members and rarely do i want the patient to stimulate an erection.  Can't he go into the bathroom or something?  Isn't there a morning wood phenomena?  Anyhow, I actually haven't asked him yet. And just chose to be yelled at by the docs this morning instead.  He did have surgery to fix his back and they discovered an anal tear which we fixed. He still wasn't having sensation (which was assessed by me waiting for several awkward moments while he played with himself in front of his mom and it wasn't under the sheets). However, we did a void trial (took out the foley to see if he could pee on his own) which he couldn't.  So we also did another rectal exam, in which he couldn't feel still but he doesn't have any more blood.  So its been several days and still no changes (this isn't looking good) so we had to consult urology and teach him to catheter himself.  So I'll update this post with edits on his progress, but the real possibility we talked about at rounds is he might have to get a colostomy bag and may never be able to use his rectum or penis again, even tho he can walk.

Now this whole situation brought up another weird medical joke/issue that is for real and people did studies on it. Throckmorton's sign. Its a real thing, tho I question how they got research grants for this. Google image it. I dare you.

ALERT

And sorry, but with alerts things were so crazy... i didn't get many pictures. Its hard when you're running about. However, we had two cases this week.

The first was a 5 month old that was lifeflighted in from a smaller hospital. Apparently the story was several days ago he was seen for nausea and vomiting, he was given antibiotics but he returned that morning for seizures.  They couldn't figure it out so they did scans. We didn't know anything but this story when we got the kid.  He was awake and looking at everyone, he moved all four of extremities, but something about the kid was off.  For example, we needed and IV and stuck him at least 8 times including on his head (for scalp veins, this is common practice for babies because they are big vessels for emergencies)... but this kid didn't cry. He just whined the first time and only once. Then he just watched us.  Something was definitely off.  We got a CT scan and saw a huge brain bleed.  Apparently it came out slowly that this was my very first case of shaken baby. The saddest part of this story is that he did not get better.  He went directly to the pediatric surgeon whom i hunted down and he said he expects the kid to be mentally retarded. He will probably never be potty trained, will only learn to walk if he's lucky and may not be able to speak.  Likely he will be put in some facility to stare are the walls and lights in permanent nursing home for the rest of his life.  I looked at the parents when we told them this and I don't think they realized until that moment. Shaking your baby, even in a moment of anger, is something you can't ever take back. Not only will the kid be taken from you but they will cease to be the kid that you could have had. After they were told, the entire staff treated the parents worse than i've seen anybody treated, they were outright ostracized, glared at, and one of the surgeons even flipped them off. (professional i know).  It was strange because it was very emotional for everyone on staff.

The other case I have to talk about quick. A lady slammed on her breaks because she wanted to avoid running over an animal on the highway. The semitruck behind her slammed into her car, shoving her into oncoming traffic where another semitruck hit her head on.  We referred to this as a semi-sandwhich. Surprisingly, she was awake and lived. Though her injuries were extensive and had quite alot of blood loss.  It took 3 medical students to suture her wounds closed and I (by myself) threw about 32 sutures.  Plus we had 1 resident sewing up her face. The weird social situation that surrounded this lady was her daughter who was in the waiting room. I went to get her after my sutures and she was more nervous than usual. I guess she was adopted as a child and had only met her biological mother (the one we just sewed up) about 2 months ago. She had no idea how to feel or what to say. It was very awkward.  This picture is of an acetabular fracture (the bony cup that holds the femur head in your hip), its on the patient's left-- and its kinda tricky to see. The biggest thing that we worry about in trauma's with pelvic fracture is bleeding. Usually if you bleed from a vessel, it will bleed until the pressure around the vessel is more than the pressure in the vessel which stops the bleeding. In pelvic fractures the bone structure is broken, allowing the soft tissue to slack. There is a lot of space in the pelvis. So much so that it could hold half your body's blood supply-- more than enough to cause death by bleeding out. However,  if your pelvis in intact then the pressure will eventually overcome the bleeding, if it is broken, you can bleed out fast, with no outward signs.

So anyway I have to sleep or I might die....

OB/GYN: No Residents

SO there is one day every so often all the residents in one particular specialty has to go to a special conference for skills tests out of the city. This leaves the hospital without a single OB/GYN resident.  This means that of course-- the shit will hit the fan, because teaching hospitals run on the backs of residents.  There is an in-house resident at ALL times for almost every specialty and the attendings are only called when the resident is in over their head or for approval of high level procedures.  Without the residents, the attendings suddenly become responsible for everything-- something they aren't used to.  This means they pull together all the students on the service and make us handle the little day-to-day details while they handle the bigger things. Things like yes, you can give tylenol to this patient with a fever or no, she cannot have any food before surgery (etc etc). These are things that we learn through out the month.  Now I am almost done with OB/GYN and the other two students are new in their first three days.  This means that not only are the nurses asking us questions but the other students are asking me questions, which the nurses notice and then start assuming i'm in charge.  BIG MISTAKE. Not because i messed up (that i know of-- which i was scared out of my mind about) just because suddenly i was getting all the calls.  And now I understand why docs think nurses can be annoying.  When i was in charge, the nurses didn't ignore me anymore they just started trying to pander to my ego, which was very confusing. Telling me I was gunna be a great doctor and how i knew so much blah blah... which would be nice if this same nurse hadn't just complained to the attending last week that i kept getting in their way and not doing anything useful. Weird. And then they started asking me just ridiculous questions. When i put in an NPO order they call me and ask is jello considered a food?  Is a cough drop? They page me overhead to ask if i can come look at this lady because she has this new rash, so i come down and find out she's had it for 4 days and there is already an antifungal written for it. I wondered if they were doing it on purpose but it was so many different floors i don't think it was. Anyhow, despite all that it was neat because i felt like i got a small taste of being a resident. I got to make tiny medical decisions and it was at least for this one day AWESOME !

It was a crazy day. We had 7 births that day with 1 attending, who was running about like crazy.  I got a phone call that we have a life flight coming in 5 minutes of a 19 y.o. who is 24weeks pregnant (remember that 24weeks is the bare minimum number that fetus can survive outside of the mom-- not guarenteed survival but possible survival).  She is having vaginal bleeding, abdominal pain, and of course she had done cocaine yesterday. Awesome right?   So she gets here and the baby's heart rate is in the toilet (i don't know much but i know the baby is tanking) and this girl is screaming her head off because she is scared out of her mind.  And she rolls in and we just divert her down the hall to c-section. We didn't scrub we didn't put on hats, we ran down the hall to the OR.  Where we ripped off her clothes, started prepping her for surgery while the doc put on gloves. At this point she's clinging to me with all her 90pounds of strength and screaming.  The nurses and doc are screaming for anesthesia who is not here and they page them stat overhead.  but the baby's heart rate is falling and now mom's heart rate gets questionable and anesthesia still isn't here. So the doc decides she's going to cut without anesthesia -- she makes the first cut and the girl is like freaking out.  Of course she doesn't let me go so they put the blue sterile sheet on top of me.  Finally anesthesia comes running up and they freak out until the doc sternly tells em to put her under NOW.  And then they intubate and i get out of her grasp and next thing i know that baby is whipped out-- most purple baby i've ever seen.  2pounds 3 oz.  And baby had to be intubated.  I still don't know whether or not the baby made it because as OB/GYN we are responsible for the mom once birth happens, not baby.  The mom made it.

But i had to leave the OR because I had to manage the other 3 ladies in labor who were quite literally delivering now. I had to go from room to room to check them and make sure baby's head wasn't falling out. And of course with one check i saw the nose and almost delivered the baby on my own. It was terrifying because here i am trying to be calm trying to coach her through the pushes, the breathing, and the contractions, nervously exchanging glances with nurse and making her run for the doctor, while i have my hand on the baby's head and PRAYING that nothing would go wrong because I wouldn't know what to do...   Luckily the doctor came in just as the head popped out.  She left me to deliver the placenta while the woman across the hall delivered. The rest of the women on the floor musta heard about it or maybe there is some crazy hormone we don't know about but man those babies just came out one after another after another after another.  So i assigned the other medical students to one laboring patient each. And the PA student who was new. And then ran about trying to transfer patients to post partum and manage the nursery transfers etc.  It was exhausting and exhilarating at the same time. And i am sure now, that I could do OB/GYN and like it.

Last patient of the day is a bigger girl who presented to ER for abdominal pain of what she thought was appendicitis. And low and behold the ER doc did an Ultrasound to see if the appendix was inflammed and oh, there is a baby. And oh she's in full term labor.  And somehow she didn't know she was pregnant.  And when i went down to talk to her, she's was eating a big mac and talking, "this happened last time with my last baby. I thought the movement was indigestion. Isn't that funny?" Half way through the exam, the boyfriend brings her 2 more big macs. Only patient i've ever seen eating big macs DURING labor. Like for real.  Plus she didn't know she was pregnant. That was also weird.

The big question is now is what do i think of ER. Do i like ask much as OB/GYN or vice versa?  Anyhow. sorry this was so quick.

OB/GYN: patient comfort & ovarian torsion

So. A few things to follow.  First just finished my 24 shift. I dunno 24 hours isn't that bad if you don't have to do it all the time, which according to the OB/GYN attendings you do.  Not to mention the malpractice insurance and suits are SO out of control. I guess several of them were being sued because kids they delivered turned out to have learning disabilities or Austism.  The saddest thing is lots of these doctors loose because  ingenius lawyers or the truth that we don't know what causes Austism-- so they use theories of anything and everything  including hypoxia during birth.

Anyhow. So the patient I described in my previous post, in the botched DiVinci robotic surgery. The one with the bowel perforation-- she's someone I have to 'round' on (check up on) everyday.  Anyway she's not doing particularly well.  She's a rather anxious person and who can blame her after being admitted for what was supposed to be an outpatient surgery and now she has tons of complications. Not just the bowel perforation which healed by the way. But also now multiple blood clots in her lungs. And today she was told she needs an MRI because they were concerned about her mental status because she forgot the word for 'hairbrush'.  Anyway I think they are only freaking out because she has had so many complications-- that they are trying to cover their asses.  But in the meantime, she's closterphobic and these tests are racking up a large hospital bill that she can no longer afford.  I was faced with an ethical dilemma when she asked me up front, "Ignore your job for a minute. Would you get the scan done?"  because the answer for me is--- no.  But if i tell her that and if i'm wrong-- then I could be sued for it. So when do you stand up for yourself and for your patient's comfort and when do you cover your ass (CYA)?  Its a shame that medicine has become more CYA than not. I ended up telling her that if she doesn't want the test she doesn't have to have it. But she should talk to the neurologist who ordered the test to make sure they had good reason for ordering it, being sure to tell them all of her problems with it and see if they thought it was necessary or if it was CYA.   It was the most legal way I could tell her-- no you probably don't need it without making the decision for her.

So there was a patient who was admitted before my shift for extreme abdominal pain.  She had multiple imaging studies that showed this odd mass that nobody could identify.  So when I got on shift, we all debated what it could be but decided to do exploratory surgery. She has been in pain for at least 24 hours and nobody could figure it out.  The image was blurry, and the mass could be attached to the uterus or the bowel or ovary or floating alone.  And the surgeons argued about who would have to go in blind, so the OB/GYN decided to just do it. Anyway we get in there and its a quick surgery. Because the mass is huge and purple and... it turns out to be the ovary and giant baseball sized ovary. And the blood supply is twisted on itself. This is a condition called 'ovary torsion' it is very rare.  Most people hear about it in males, the dreaded twisted testicle that causes extreme pain and is an emergency.  Its easy to twist testicles but very hard to twist the ovary.  Anyway I got a picture. Its something that you only read about in textbooks...

OB/GYN: Fibroids part 2

So i was a little unsatisfied with my previous post on fibroids, since I needed to make sure to get more facts straight.  Also i wanted to post pictures of an intact uterus with fibroids. SO i have this post :) 

This is obviously not a normal uterus. It is enlarged because of the fibroids. A normal uterus is about the size of the palm of your hand. Of course that is without a baby or fibroids inside.  Anyhow. You can see the cervix and you can see the circular fibroids all over the uterus

• Known risk factors are African-American descent, nulliparity, obesity, PCOS, Diabetes, hypertension
• fibroids are hormone dependent. So after menopause and before your period, you don't have fibroids
•  seals an dogs also suffer from uterine fibroids
• there is a genetic component but it doesnt mean you'll get them because your mom does...
• we don understand why or how they develop
• the only treatment for fibroids is hysterectomy

 This uterus is 8 inches long and its 470 grams. It was bigger than some babies.  This lady was experiencing significant bleeding and a weight gain.  And that's about all i know.   And i'm bored already of fibroids....

asdf

OB/GYN: malformations

so.  I know i've made the sad parts of ob/gyn obvious.  But I have followed up on one of the babies born without a right ear.  I wasn't allowed to take a picture, because she has other malformations and the parents didn't want her seen as a freak.  So I will just tell you about her.  She has a cleft lip and palate. Her head shape is just a little too round and her right jaw is obviously smaller than her left side.  The chromosome typing hasn't come back yet.  I am doubting it is any chromosome problem since its not on both sides, but then i guess what happens in books isn't always what happens in real life.  The only other way she could have gotten this way is if the mom had ingested something toxic to the developing fetus. Any illegal drug will do or a few different kinds of actual medications. But mom of course denies these possibilities. 

Anyhow, what I am able to show is her MRIs.  You can see that she has a big malformation in the bottom part of her brain where her cerebellum would be.  This congential lack of cerebellum is called dandy-walker syndrome.  In most cases, it refers to a complete absence of the middle of the cerebellum called the vermis.  When this happens, the person is usually just fine and develops normally.  Our path teacher once said, "i walk just dandy without my vermis."   But her malformation isn't just the vermis, its the whole cerebellum is smaller than it should be.  See the black triangle at the bottom of this picture. That black shows empty space and just so you know, there shouldn't be just empty space in the brain like that. If you refer to some of those neuro pictures from way back when i'm sure you can compare for yourself.

This picture here, is the more standard MRI. Here not only can you see the cerebellum problems but you can also see the shape of her head. The weird jaw line.  You can see that she has neonatal teeth (most babies aren't born with teeth).  You can see that her eye sockets are smaller than normal and even her brain tissue just isn't quite right.  You can  see the palate malformation as well. 

Alright here i'll insert a labelled pic.  Its not terribly obvious but its the best i can do for now.

OB/GYN: Fibriods

So i Finally got to see a very awesome surgery... the only surgery of the day (but don't worry, that doesn't mean a day off for me, it means more ob).

It was a partial hysterectomy with a known 10cm fibroid.  A 36 y.o. woman who wanted this surgery because of extreme abdominal pain and significant bleeding during menses. This was presumed be because the fibroid, which was outside of the uterus. She tried for seven years to conceive and finally decided to accept her fate. And decided on the surgery.  She wanted to keep her cervix and ovaries which is why it is only a partial hysterectomy. When we opened the abdomen, we found the fibroid- which is a ball made entirely of excess muscle. Before you ask, we have no idea why some women get them and others don't. We do know that obesity is a very high risk factor, though.  Anyhow below is the fibriod I'm holding. It is shaped like a heart.... see

However, the real surprise was her uterus. It was very large and there were so many blood vessels.  We had to cut the uterus in half to get it out of the incision so, when we cut we found that the uterus was filled with nothing but fibroid tissue. It filled the uterus so completely there was no way she was ever going to conceive or come close to stop bleeding.  If we hadn't already cut out a fourth of the uterus we could have cut out the fibroid and allowed her to try for a kid. But she had already signed the consent and we had already cut off the uterine blood supply.

For those that don't know: the uterus gets up to a quart of blood a minute.  So imagine cutting that artery and the sheer amount of bleeding. Women can and do die because the uterus breaks (during labor, trauma, etc). So cutting the uterus results in significant amounts of bleeding and with fibriods, this lady was no exception. She ended up getting two bags of blood because we kept getting bleeders. It was crazy fun.

Anyway, below are the pieces of the uterus... look at how thick and almost meaty it is.  Believe it or not, the strongest muscle in the body.... the uterus. Yeah. Take that. 

EDIT: I just went back and updated a few of the previous posts by adding more pictures, etc. And I added a few new posts, check out the general surgery section.