Ortho: More surgeries

Don't expect my ortho entries to be long (I may even skip a day or two) because unless there's surgery to be done, I don't have much to write about. We had four surgeries scheduled this morning. The first two were knee scopes; I read up on knee surgery yesterday in case I got pimped but it didn't happen. The third was another carpal tunnel release, and the fourth was a dislocated shoulder with a Bankart lesion repair. A Bankart lesion is basically a tear in the shoulder labrum (the cuff of cartilage that the humerus fits into), but as for me, I had no clue what I was looking at. An entire piece of bone had broken off this guy's shoulder and was just taking up joint space, and it was hard to get it out. The PA and Dr. JD had a lot of struggle in getting rid of that piece of bone (not-so-affectionally dubbed "that piece of s***") out, and by the time they succeeded we'd spent over an hour in surgery, well past lunch time. Luckily some drug reps brought Macaroni Grill lunch so we were able to indulge in bowtie pasta, salad, bread (YUM!), and cookies afterwards.

Ortho: Lecture and Work

Jacob survived his first night of call with my former surgery team; last night he was in the OR until almost 11 pm because of two add-ons. Yikes. He thought my team was nice (and got along the best with BR, not surprisingly), but thought JB was a bit on the arrogant side the way he liked to pimp the students. I said JB was probably entitled to it since he's a chief, but Jacob said not all chiefs had to be that way. This morning in lecture, we had a doctor from the former Yugoslavia talk to us about being a doctor in the warzone in Kosovo. He had various pictures of war victims to share and also told us about using spatulas and spoons to retract at a time when he had to treat victims in a cave. Makes one really appreciate how the US has modern technology in the hospitals; I imagine not having a Bovie would be unthinkable to many surgeons. We had two quizzes in lecture today since we didn't take one last year, but because Dr. B was late we were in lecture until almost noon. That was fine; I knew I wouldn't be doing much at Dr. JD's clinic. Although, as Elizabeth pointed out today when we were chatting before class, it's probably a good thing Dr. JD doesn't talk much; it's better than getting yelled at and being told that you're s*** (or something equally miserable). We also found out where our family medicine rotations will be; I'll be at the JPS-based Polytechnic Community clinic. If anyone knows anything about this site (i.e. hours), let me know! But seeing how it's JPS, I'll probably have long hours.

I'm starting to see a very obvious trend with many of the patients with knee disorders: obesity. =/ There's going to be four surgeries scheduled tomorrow, among them another carpal tunnel release and an ACL repair. Time to brush up on my anatomy in case I get pimped...again.

Ortho: Nothing to do

This morning there were two surgeries scheduled, so I arrived at 7:00 a.m. The ortho surgeon, Dr. JD, didn't arrive until 7:30-ish, and he barely acknowledged I was there. I kind of expected that after hearing from others who have had him, but it was still kind of awkward. The first surgery involved decompressing a frozen shoulder, where the doctor put a scope in the arm and used a metal instrument to debride tissue-like adhesions from the cartilage (kind of weird looking). The second surgery was a carpal tunnel release that took a grand total of 5 minutes to do. Since I wasn't allowed to scrub in, I could only watch (and get pimped on the median nerve and its functions). But for the rest of the day, I alternated between following Dr. JD and his PA, Rodney, to different rooms to see patients at the speed of light. Several of them had pain in their knees or shoulders and received steroid injections. Others were just given reassurance. Through it all, I might as well have been a ghost. A few patients acknowledged me with a smile, but rarely did Dr. JD introduce me to his patients. If a clinic day is like this, I hate to think what an OR day is going to be like =( I get the feeling I'm not going to learn very much about ortho these next two weeks.

Ortho: Day One

Nothing much happened today. I went to All Saints to get "certified" (took a HIPAA quiz) and then swung by JPS to talk to Margie about not being able to evaluate my surgery rotation online. I stopped by the call room to use the nearby computer and saw Jacob and Natacha there waiting for their residents to call them to tell them where to go. They, like me the first time, forgot to press the # sign after entering the number. Jacob was on my old team, so I paged JB first to see if he was in surgery (he was), and then paged BR. It was pretty coincidental that I looked at my calendar last night to see what my team would be doing this morning, and so I knew only JB and BR were here today (BB and RB had the day off). And since today was pre-call day for my team, BR just told Jacob to go home and come back tomorrow morning. Lucky him =)

In the meantime, I swung by the Med Education office to fill in a request for an academic month, then talked to one of the ladies in there (Ann, I think) about what rotations were good for 4th year. She showed me a list of potential openings for ICU rotations at JPS and radiology rotations at JPS or the VA hospital nearby. I was amazed to see ICU spots almost completely filled and wondered if I should sign up for a spot too. Then Ann told me that I could also schedule a radiology/radiation oncology rotation over at the cancer center near my house. I think I may do that, it's just a matter of scheduling when to do it since radiology spots fill up fast. *sigh* I don't know what to do for my August rotation, where can I do a medicine sub-I?

Afterwards I went to the ortho doc's clinic to find that he wasn't there (probably still doing surgery and I didn't know if I was supposed to find him in the hospital or not). His PA was there, though, so I just followed him on a few patients. So far ortho doesn't seem very interesting (there probably would have been more to see at JPS), but I'll give it a shot. The schedule seems a lot better (weekends off for sure) so I'll have more time to study. This doc does some surgeries in the clinic, so I'll have to be there at 7 a.m. tomorrow. *sigh* Still, better than 6:15 a.m.

Last Thoughts on General Surgery

Two days later, I still feel like crap (stuffed nose, sore throat) but am enjoying my last day off before ortho begins. *sigh* The last four weeks have been hectic, but it could have been a lot worse. I never had to stay up all night with the interns (I always got at least 3-4 hrs a night) because RB and BR usually handled everything on their own. Had there only been one intern on the team (as was the case with other teams) then it might have been a different story. One interesting thing Manisha told me was that last year, there were two third years per surgery team instead of one, so they took turns going into surgeries (just like with obgyn). But with only one med student per team this year, my peers and I had to scrub in on all the surgeries with the chief or the junior, so we have it harder. I saw a grand total of 27 surgeries this month. The majority of them were lap choles and PEG insertions (of course), but the ones that stood out (fem-fem bypass, Heller myotomy) made it worthwhile.

Then of course there were the traumas that came in while I was on call. I knew the names of two victims (the AA woman who died on Friday and the woman killed in a murder-suicide on the 13th) so out of curiosity I googled their names to see what I could learn about them. The woman from the 13th, it turned out, was shot by her estranged husband near her apartment before he turned the gun on himself; apparently he had a history of being controlling and emotionally abusive. They left behind a young daughter who is now staying with her grandparents. The AA woman and her husband, as it turned out, were victims of a robbery. Police say three men forced their way into the apartment, demanded to know where money was kept, then shot her and her husband before leaving. One of those men was a known white supremacist, which was why people thought this was a hate crime at first. *sigh* At any rate, all three men have been arrested.

I hope ortho will be kinder to me.

General Surgery: Friday Call, Last Day

Today was my last day of general surgery, but since I was scheduled to be on call, I didn't know whether I'd be allowed to leave early or not. Sure, I'd told JB that I didn't want to stay overnight, but would he remember? One thing he did remember: he brought me a bundle of books that he used in med school to help me for USMLE2 and the shelf exams. Wow, talk about generous! Afterwards, I rounded on two of our patients, one of whom I've been seeing almost every day for this entire month. He was an overweight man who accidentally fell in his driveway and ended up with a C3-C4 spinal contusion that left him with very little strength in his arms and legs. Now he just lies helplessly in bed, waiting for a nursing home or rehab center who will take him, and lately he's been vomiting a lot and had explosive diarrhea last night (but not C. difficile). I'm sorry I won't be able to follow up on him and see where he ends up, as I have with other patients that I've seen since day one. A couple who got hurt in a MVC got sent to rehab centers in San Antonio. A young woman with gastric cancer keeps coming back to JPS every time she has abdominal pain, but today we turned her away for the 3rd or 4th time. A 15 year old who was hurt in another MVC is still in a vegetative state. And sadly, the 19-year-old African American girl who was shot on MLK day was taken off life support; this evening they took her to the OR to harvest her organs for donation. I didn't even know they were donating her organs until I saw "Life Care: Organ _________" on the OR board, and identified her by her ICU room (which I knew all too well) Still, at least some good comes from this tragedy. For patients who need heart, liver, lung, or kidney transplants, someone has to die for others to live, and tonight or tomorrow, someone's beeper will go off alerting them that they have an organ available. I've always been a strong supporter of organ donation, so for all its sadness, there's also some hope.

My first surgery was a Heller myotomy, used to treat patients with achalasia. The outer muscles of the esophagus are cut to relax the LES, and then a Dor fundoplication (fundus is wrapped around the front of the esophagus) was done to prevent reflux. The staff attending was also Corey's preceptor, but I got to scrub in while he stood in the background and watched. The myotomy was really cool, but the doctors made one mistake by accidentally slicing through the inner layer of the esophagus (that had to be sewn up). After that, we had a brief lunch break (JB got some pizza from the OR nurses and shared it with the rest of us). Only after talking to RB did we realize that BR never showed up at work today, and only then did JB check his voicemail to hear that BR was sick with gastroenteritis. BB thought that was suspiciously inconvenient since all general surgery residents have an exam to take tomorrow, and said that BR had better not be pretending to be sick in order to study. "No, he does sound sick," said JB, and to be sure, he called BR on the phone to see how he was doing. BB and RB jokingly made snide comments within earshot, but JB said, "The others are giving you grief over here, but I know you're not that kind of guy" and proceeded to ask BR if he was feverish and "which end it was coming out." Apparently BR can't stop throwing up, but said that he'll try to come to work when he's ready. *sigh* Poor guy. It sucks to be a resident b/c you can't really miss work.

After lunch, we did an emergency open appendectomy on an HIV/Hep C patient. Because of his blood status, we all double-gloved except for the attending; he didn't think double-gloving made much difference. It was clear that something nasty was going on; yellowish fluid was suctioned almost immediately from his abdomen (the attending called it ascites) and the operating area soon smelled like a really bad fart. After shifting through lots of bowels, the residents found the culprit: a perforated appendix complete with a round fecalith. I later showed Corey the fecalith up close, but he said he didn't want it After the appendectomy, we had three more lap choles to do. JB, BB, and I started on the first one, but immediately ran into trouble. For whatever reason, this was the worst gallbladder we had ever seen, almost completely covered with fat and adhesions and its parts difficult to distinguish. There were times where we had "bleeders" where BB accidentally nicked vessels by mistake, and then they had to scramble like hell with the stapler to try to isolate the vessel and stop the bleeding. I had to hold the camera, but since I still had a cold and was not out of the woods from the fever just yet, I sometimes lost focus and tilted the camera the wrong way. "Uh oh, she's quitting on us," said JB, who knew it was my last day. The longer the surgery got, the shorter tempers grew, and at one point JB told me, "You fail!" when the view went awry, even though I knew I was holding the camera straight and it was BB jostling the fat that messed up the view of the abdomen. We started surgery at 3:40 pm, and we didn't get out until around 7:30 pm. Imagine that, nearly 4 hrs on a gallbladder. In that time, our attending was able to do the other two (uncomplicated) lap choles, then come back and watch us finish.

When I got out of surgery, I went to the call room and checked my voicemail. Several birthday messages were heard, but instead of making me happy, I felt upset. Being on call by myself in a huge county hospital was not the way I envisioned spending my 25th birthday. Still, I sucked it up and went back downstairs in time to eat and see a patient who had a hip abscess/cellulitis, quite a combo. Just as we were prepared to drain it, RB and I got called to a Level 1 trauma. Another GSW patient, this time through the right chest; he was awake but frantic, but his biggest problem was a collapsed right lung. BB put in a chest tube while Manisha (4th year) and I held his legs down. At one point he tried to kick out at us and I said, "Sir, relax, please!" At this, JB laughed and said, "He's not going to relax just because you said please." *sigh* Good point. In the next bed, another patient who'd been unconscious from a seizure suddenly woke up and began thrashing about; it took several paramedics to hold him down. *sigh* Craziness in the ER. When things calmed down a bit, I helped incise and drain (I&D) the patient's hip abscess with guidance (and backseat slicing) from RB. My cuts were too shallow, and I couldn't quite squeeze out all the pus like RB did, but now I have an idea of what to do.

Luckily for me, JB let me go around 11:00 pm (but only after I asked him). So I got to spend some quality time at home before the day ended. *smiles* Happy Birthday to me.

General Surgery: Guess Who's Sick Again

Last night I had a sore throat and a bad case of the chills, and I knew immediately that I was sick again...for the third time in three months. >_< Today after rounding on patients, I went to watch BR close the abdomen of a patient who had a toxic megacolon taken out on our last call day. JB had called it the ugliest colon he'd ever seen and showed us pictures yesterday.
It was gross-looking, all dark and stuff, but what stood out was that it was 9-10 cm in diameter (as opposed to the usual 3 cm) and about 2 ft long, looking very much like an anaconda. BB joked that JB would probably stick that picture on the wall beside his kids' pictures b/c it was such an unusual case. At any rate, today's surgery was to clean out the patient bowels and resect her ileum to create an ileostomy (she doesn't have a colon anymore, after all)

The patient's abdomen had been left open (with towels packing her bowels to keep them from falling out), so it was flushed with saline before the ileum was isolated and looped through an incision in the abdomen to create an ileostomy. The incision ran from the xyphoid to the pubic bone (VERY long), so BB had to throw in several deep sutures to be able to approximate the edges together so I could staple the edges together. This was BB's first solo ileostomy, and he got so into doing it that I wasn't allowed to do much more than apply tension to the sutures. *sigh* One of the worst parts was having to wait 15+ minutes for an ostomy bag on an empty stomach and fever; there were times where I was tempted to pass out. Finally BB let me go, so I went back to the lounge and chatted briefly with Dustin and Blakely (apparently Dustin never took any days off, so Blakely was telling him to be more aggressive and ask for days off in the future) before going home and sleeping for the rest of the afternoon. I feel a little better but not too much. I just need to be well enough to stay alert during surgeries tomorrow.

General Surgery: The Shortest Day

This morning we had lecture at the Cancer Center downtown (very nice building, I might add) b/c it was convenient for Dr. B, and the conference room we were in had a kitchen full of sodas, iced tea, and even wine that we could help ourselves to (though I doubt anyone drank the wine). I ended up splitting a Coke with Corey b/c he said he wasn't going to drink an entire can. Afterwards Jedd and I ran into Dina in the parking lot and she gave us a ride to JPS so we wouldn't have to walk (thanks Dina!) I only saw about 2-3 patients in the general surg clinic, then went to breast clinic around 2:30 pm. To my surprise, there was only one patient left to see. BR was happy to hear that b/c with me seeing the patient, he got to go home early (not to mention the guys on my team aren't too fond of the "booby clinic") The attending was an elderly doctor from UTSW who's hunched over, but still a good teacher. My one patient had felt a lump in her breast that has since disappeared (normal mammo). We'll follow up on her with another mammo in 5 months. The best part about today: I was home by 4 pm, which almost never happens.

I asked JB if I could take off early on Friday (in other words, not stay overnight for call) and though he said yes, he asked if I had any exams coming up and pointedly asked when my shelf was. The truth is, I haven't really started studying for the shelf at all, but I didn't want to tell JB that and have him think I'm a slacker. I redeemed myself slightly today by removing a patient's staples without him telling me to, but that's small stuff. *sigh* Now I must seem like I'm lazy...

General Surgery: Monday Call (MLK)

After two glorious days off, it was back to JPS on Monday morning. BR pointed out that it was also MLK Day, and commented on how sad it would be if a fight broke out between blacks and whites today. I certainly hoped that wouldn't be the case. The morning started out with a lap chole, and once again I got to hold the camera. I think I'm getting better at it =) The second surgery was a twofer: an umbilical hernia repair and a lap chole. BB got called away to do a colonoscopy ("Great, I have to leave surgery to look up someone's ass") so JB told me that I might get to do actual surgery now. My job: poke a needle through the mesh in the abdomen and help sew it back into place. I got the needle in on the first try and got excited to do more; JB noticed and said, "You looked like you were about to yank that needle from me there, that's good!" He must be glad I'm being more proactive. We get free lunches from drug reps in the surgery offices, but today's lunch was probably the nastiest take-out Chinese I've ever had. The ice tea itself tasted like there was algae in it; talk about gross. After that there was another incisional hernia repair (a woman went to Mexico for lipo and ended up with a hernia; there was even HAIR in the hernia from the surgeon in Mexico) and an ileostomy removal. Fortunately we went to dinner after that b/c I was getting really hungry. JB, BR, and I sat down briefly for dinner when the trauma pager went off.

The trauma: 81-year-old female fell backwards and hit her head. Because it was a non-operative trauma, JB sent BR to see what was going on, so JB and I got to finish our dinner. It was a sad case; the woman's brain was bleeding so badly that the midline of her brain had shifted over about 2 cm and was herniating into the brainstem as well. JB called her son and his wife and explained to them (in the dreaded private talk room) that his mother was essentially brain dead. Her son asked many questions and asked for a repeat CT, saying that his mother didn't have a DNR and he wanted to give her until morning to see how she fares. I watched JB and BR testing her cranial nerves; she had no gag reflex, and when her eyes were lightly poked with a cotton swab, she didn't blink (but she did have tears form). Later, during the night, she would regain her gag reflex and would spontaneously move her legs, but those were not purposeful movements. In the long run, the outcome will not change.

BB was doing a surgery and needed help, so JB sent me ("the med student") to the OR to see what could be done. It turns out RB had admitted a patient complaining of a recently incarcerated inguinal hernia that had been there for eight years, and it was so huge that BB and the attending ("Mac") were having trouble finding the hernia sac and other cord structures. It was possibly the worst hernia BB had ever seen; even Mac said it was ugly. When they finally found the sac and sliced it open, a huge amount of small bowel tumbled out (at least 2 feet) BB and Mac had to struggle to shove all that bowel back through the incision into the abdomen, but since it'd been hanging out for 8 years it kept coming back. Stubborn piece of bowel. In the middle of the surgery, the trauma pager went off three times in the span of 30 min, with the 1st two close together. The first: GSW to the head, GCS (Glasgow coma scale) 5 /15. The second: GSW to the head, GCS 15/15 (lucky). The third came thirty minutes later: GSW to chest and buttocks. Mac stuck around for the hard parts of fixing the hernia (they had to find a way to recreate the floor and isolate the hernia sac) before joining JB, BR, and RB in the ER; that left BB and me to sew up the hernia. We didn't finish until close to 10:30 pm.

Sadly, the shooting incident in the ER was racially motivated; some white guy randomly went to a predominately-black apartment complex and started shooting, hurting a young couple (the first two victims) in the process. Somehow that same white guy got shot too (the third victim), but his wounds were superficial as crap so the police were waiting to take him to jail. The boyfriend had the 15/15 GCS so he was all right, but the girlfriend (she was only 19) was not in good shape. The bullet had fragmented into many little pieces across her brain, and she, too, was almost brain dead. Around midnight, her family members started coming to the ICU, some refusing to enter the room, others leaving in tears. It was hard to watch. No parent wants to see their child on the verge of death in a hospital bed, especially when the reason for it was because someone wanted to commit a senseless crime. At 1:00 a.m. RB told me to get some rest; there was nothing else I could do but watch.

I slept until 6 a.m. (I had a roommate, a 4th year doing her ICU rotation; she snored a little so it was hard to fall asleep) and then got up to round on patients. Somewhere on the 3rd floor, I saw Blakely's medicine team, and her attending mentioned BR's name and something about how "interns have no right to talk that way." I wondered what the heck BR did to piss someone off this time (JB nicknamed him "Road Rage BR" for a reason), and I was alarmed when the medicine attending said he planned to write a note in BR's file which could possibly affect his prospects of finding a job after residency. Later I asked RB what happened, and he said apparently BR took a patient's file from the attending's stack without permission, and when the attending said he was still using that file, BR had replied something along the lines of, "So what?" *sigh* You just don't do that. A great deal of medicine is about being respectful to those above you. This morning JB told me, "Call me J!" when I called him Dr. B, and I had replied, "I can't do that." Mac (the attending), who was nearby, had said, "That's right." Likewise, BR has said I could call him by his first name, and RB is only two years older than me, but I still call them Dr. The gap between a med student and an intern is still pretty broad.

General Surgery: Thursday Call

The morning began with a trauma conference (if BR hadn't told me I wouldn't have known about it) in which the first case discussed was the GSW patient who died in the ER on the 10th. The attending in charge of the discussion questioned JB on why he chose to open the patient's chest on the left side when one of the bullets had clearly struck the right chest (the ER rooms are not designed for major surgical procedures, so the incision had been made along the side of the rib cage). "In my day, we did open-chest thoracotomies in the ER," he said, and related a story of how he opened up a chest to find a tear in the aorta that was easily isolated and repaired in minutes. "Now can you imagine trying to find that tear with only a limited view of the chest?" In his defense, JB said that the patient had lost so much blood from the initial shooting that he wanted easy access to the heart in order to perform internal heart massage. Dr. T, the attending who was with us that afternoon, backed him up by saying that there was almost no bleeding when JB opened up the victim's chest along the side. "He was pretty much dead," said Dr. T, and opening his chest wouldn't have done much good to save his life. The attending in charge nodded, but stuck to his belief that surgeons these days were too timid to do thoracotomies in the ER.

This was my first full call day on a weekday (my previous call days fell on weekends, and I missed five hours of surgery due to lecture), so after grabbing a burrito from the family clinic ("Christmas"), our surgery day began. Our first patient was a man whom I talked to at the clinic; he had an incarcerated ventral incision hernia that was causing him a lot of pain. Inside, the laparoscope showed that he had a bunch of omentum stuck to the roof of the abdomen, and that was easily removed. The doctors then inserted a mesh laparoscopically and proceeded to sew him up that way. JB had initially written "HI" on the mesh to make the orientation clear, but then they realized that "HI" was a palindrome (if you fold it along the middle) so that was a bit pointless. At one point JB pointed to a pulsing wall and asked me what that was. My first thought was "aorta" but he said no. The obvious answer: the heart. *sigh* I never go for the most obvious answers; JB must think I'm an idiot. The patient started complaining of pain almost immediately after waking up; he's the most verbal post-op patient I've ever met to date. Next was another PEG insertion followed by hemorrhoid removal (with a harmonic instrument that works better than a bovie).

The next surgery was my very first lap chole, but with both JB and BB in the room I expected my role to be very small. Then the trauma pagers went off midway through, and since JB was the chief, he told BB to go to the ER to see what was going on. BB was visibly disappointed (this was his first time to do a lap chole and he wanted to finish), but he hasn't had enough training to do a lap chole by himself yet. JB then gave me the job of holding the camera and keeping it centered on his laparoscopic bovie. Easier said than done; it took me a while to get the hang of maneuvering the camera and there were times when JB got exasperated b/c he couldn't see what he needed to see. "You're the cinematographer," he said. "Zoom in. Get centered." I felt bad that I couldn't get it quite right, but I did my best. Afterwards I got to help suture the incisions where the Trocars were inserted, and JB said I was pretty good at suturing. *Thank you Dr. M for showing me how to suture back in ob-gyn* I hate to think what he'd say if I told him I had no clue how to tie knots. There was a second lap chole to follow this one, and I hoped to redeem myself as "camera person" in the next one. BB was doing a rectal condyloma excision in another room by the time JB and I left the OR, so I stayed to watch while JB went to do something else. At the end of the surgery there were about 4-5 nurses working on the patient so I stood back and watched (didn't want to get in the way) while BB got on the phone and started dictating. Suddenly, one of the nurses turned to me and said rudely, "You know, as a medical student, you can start by helping us around instead of just standing there doing nothing." Another nurse chimed in, "Yeah, or we won't help you or your doctor."

I was floored, but before I could reply, the first nurse jerked a thumb toward BB and muttered, "Don't be like him" before telling the others good work and leaving the OR. Talk about making me feel like s***. I was already worn out from thinking that I let JB down, and now I had nurses jumping down my throat. A part of me wanted nothing more than to hide in the call room, but instead I went to the first OR (where the scrub tech was setting up for the next lap chole), and asked if there was any way I could help him. He was already gowned and gloved so he told me to pull some gloves, equipment, and needles for him. Fortunately he was friendly and told me a bit about himself as he continued setting up equipment. He does contract work where he travels to different hospitals around the nation, offering his services for 13 weeks at a time and making more money than scrub techs who stay in one location (he's single so that lets him have this lifestyle). This is his second time at JPS, and he likes it because the pay is good and the cameraderie between doctors and nurses was better than he's seen at other hospitals. I told him about my nurse encounter, and he said that he knows from experience that it's hard to please everyone. Different doctors prefer specific instruments and he has to learn what they like to keep them happy. Likewise, nurses are busy because of all the care they have to provide for their patients, and if their jobs can be made easier in any way, that makes them happy. "Like now, when you helped me out, you were doing a nurse's job, giving her less to do," he said. He also said that because he just did a lap chole with JB, he knows what instruments JB likes and has extra instruments set up in case JB needs them (we didn't have extras the first time). At any rate, after talking to this scrub tech, I felt a whole lot better.

The second lap chole was similar to the first one, except both BB and Dr. G (the attending on call) were in the room the whole time. That meant there were two additional people telling me how to maneuver the camera (sometimes JB had to move my hand for me), but fortunately I was better the 2nd time around. The scrub tech had told me that some doctors get motion sickness when an inexperienced camera holder shakes too much, so I made sure to hold the camera as still as I could. This time, BB got to do the entire surgery and he was excited about. Then we had a small problem: the gallstone in this lady's gallbladder was so huge that BB couldn't pull it out of the incision site. After a hapless game of tug-of-war he finally made the incision larger (JB's orders) in order to get the darn thing out; it was almost 2 cm in diameter! That was the last surgery of the evening, thank goodness. I saw Dr. K (from ob-gyn) in ICU and said good evening. His response: "No, it's not." With no traumas and some free time, Dr. G treated everyone on our team to pizza (sadly I already ate before the pizza arrived but still ate a slice to be polite). BR started chatting about how he worked as a bouncer before med school and described his various skydiving adventures to us. Given his sometimes brash mannerisms I can easily see him as a bouncer. After pizza, we rounded on patients one more time and then JB told me to get some rest. RB said he'd knock on my door if anything happens (Dustin didn't leave me the trauma pager).

I went to bed around midnight and slept until 6:15 when a fire alarm went off, waking up briefly at 4:00 when my foot fell asleep. This was the most sleep I've ever gotten on call and I was a bit worried when I went downstairs and RB said, "Look who's joining us" but it was all right. The only "trauma" that came in was a stab would that was about one centimeter deep (and the patient left AMA anyways), and RB spent a great deal of the night trying to fix someone's PEG so there was nothing I could have done. I then went to round on our patients (we only had 12-15!) and began with the ventral hernia patient. When I went to see him, he spent about 10-15 minutes talking about how much pain he was in, how the medicine was not working, and asking what I could do to help him feel better. RB came in just as I was saying goodbye and quickly left the room, and I heard RB say, "Wow, you must have scared her off." Later, as I finished my note, RB came in shaking his head and saying, "He just wants pain meds." Afterwards I saw another PEG insertion (for the lung cancer patient who couldn't talk) and held the hand of a woman having an EGD/colonoscopy. When JB saw that, he said I get points for empathy (something that surgeons don't seem to have time for).

Thank goodness I have the weekend off; I have a ton of studying to do.

General Surgery: Conscious Uncertainty

This morning we had case presentations, and to my dismay Dr. B called on me to present. I was sure I'd suck since I had no visual aids (unlike Jedd's powerpoint presentation), so I basically pulled out my report and described what I saw in a femoral-femoral bypass that BB did in my first week of rotations. Dr. B then proceeded to pimp me on peripheral vascular diseases, indications for a fem-fem bypass, and more; sadly I didn't know the answers to most of them =( Then I was the only one who spoke up when Dr. B asked what a Swan-Ganz catheter was (I had JB's midnight pimping to thank for that one) and he ended up having me go to the blackboard to write out hemodynamic values and figures. I was up at that board for a good 30-45 min. *sigh*

After lecture I drove back to the hospital in time to see the end of a CEA (carotid endarterectomy). I wasn't too disappointed though; there was another one scheduled for later in the afternoon. At lunch I saw Kathy H and Dr. D from obgyn; funnily enough, we all had JB teach us surgery at some point or another. The second CEA was delayed b/c anesthesia had trouble starting an arterial line, so we rounded on patients in the meantime. Then when surgery began, JB started pimping me about structures in the neck (i.e. where does the recurrent laryngeal nerve lie on the right? On the left? What's this nerve here?), and I struggled on a lot of them. Now he must think I'm a total dumbass. The only question of his that I was able to answer with certainty was identifying which nerve ran beside the carotids to the organs (the vagus nerve).

"See, that's good, what I'm aiming for," he said. "When we first start out in medical school, we don't realize how much we don't know. That's called unconscious uncertainty. Then we become aware of how much we don't know, and that's called conscious uncertainty. We then study harder to increase our knowledge base but still need help sometimes, and that's called conscious certainty. Once you don't have to think about something to know you're right, then you've reached unconscious certainty, and you've got it made."

I know I'm stewing in conscious uncertainty, big-time, and I plan to read up on lap choles, hernia repairs, and hemorrhoids before tomorrow so that I won't be as stupid as I was this afternoon. I did spent a good part of the surgery holding the overhead lamp straight (it kept going crooked), which was a nice waste of time and left my arms sore. This was even more tedious scut than retracting. Luckily someone later came in to tape the lamp in place, since as JB pointed out, I spent too much money in med school to be a designated lamp holder. *sigh* This wasn't one of my better days.

General Surgery: Another Clinic Day

This morning in TeleEast I asked JB how I was doing on my rotation and if there was any way I could improve. JB said that I was doing a good job in the hospital (arriving on time, writing progress notes, seeing patients in the clinic), but knowledge-wise, I needed to brush up on that on my own.

We had general surgery clinic in the morning and vascular clinic in the afternoon. In one morning, we scheduled 3 left inguinal hernia repairs for the same day; talk about nuts. For the first time, we were able to see all the morning patients before noon. Lunch was free since there was a drug rep in the clinic; good stuff, too. Vascular clinic is hard b/c most times patients have no idea why they are there (usually sent by their PCPs). One guy talked about chest pain and shortness of breath, but he was really scheduled for follow-up on his carotid arteries. There was one interesting case: a 40 year old man presented at the clinic two months ago for endocarditis brought about by a tooth abscess, and by accident, the cardiologists realized that his aortic valve was malformed (congenital defect) and practically non-existent. He got an aortic valve replacement, and now he's doing so much better (before he was always tired, dyspneic), almost like he's got his life back. He was also thankful to Dr. A (vascular surgeon) for making his scar look nice, almost decent, instead of looking like a zipper down his chest. I passed the word to Dr. A =)

At the end of the day I reminded JB that I have lecture tomorrow, and he was disappointed b/c he'd hoped to show me an endocardectomy tomorrow (hey, I wanted to see that procedure, too, so the disappointment went both ways). "What are you going to learn in lecture that's better than what you learn in the OR?" he asked. One of the nurses said, "We had this same argument last week" and said that one of the residents wanted to keep my classmates around to help out in clinic b/c he was working alone, but they had to attend lecture b/c it was required. When it comes down to it, students have to attend lecture. I'd rather be in the OR, too, anyway.

General Surgery: Sunday Call

Whew, thank goodness I got Saturday off; I really needed the break. Sunday morning started out the usual; we rounded on patients, then went to the ER to see any traumas that needed to be seen. One of the first guys who came in had a stab wound beneath his ribs; BR probed it with a cotton swab and found it to be about 4 cm deep. CT didn't show any peritoneal penetration, but it couldn't be ruled out so arrangements for an exploratory laparoscopy were soon underway. BB would be doing the exp lap since JB was out of town (he didn't come back until 4:00 pm).

Then a fresh trauma was called in: victim with GSW to the head, ETA 9 minutes. This sounded like a case we saw last week, so we all gowned up and got ready. When the paramedics brought the patient in, however, I was caught off guard when I saw that it was a young female in her twenties. There was blood all through her hair and her left eye looked completely swollen. The police had the story: apparently the girl's boyfriend shot her through the eye in a fit of rage before turning the gun on himself (and did the job properly) By the time she got to the ER, she had PEA (pulseless electrical activity) from all the blood lost; we couldn't palpate a pulse anywhere. Sometimes after CPR we'd feel little blips of pulse, but it was rarely followed by another one. Her hands and feet were pale and cold (all the remaining blood had gone to the internal organs), and a blood transfusion did nothing to improve her volume. A doppler was used to find her heart, and while her heart was visibly twitching, the attending (who also happened to be Corey's preceptor) pointed out that her heart muscles themselves were not contracting. Time of death, 13:51. *sigh* This was a sad case, even worse when she was rolled over and I saw that the sheets and the backboard she was riding on were completely soaked with her blood. I had to put her clothes in a paper bag to accompany her body to the ME's office and hold the backboard while the nurses scrubbed it down. Later I found tiny specks of blood on my sleeve, but it was nothing a wet paper towel couldn't take care of. Still, it was unnerving.

Corey was waiting outside when I came out (he didn't see the trauma), so I filled him in on what was going on. He said he was going to see the exp lap on the stab patient with his attending, so I took that to mean I wouldn't be able to watch. While BB went to surgery, I followed BR and RB to McDonalds for lunch and then ate in the Commons (lounge) b/c the guys wanted to watch football. There was a Cowboys vs Giants game later in the afternoon, and my interns were hoping no traumas would come in so they could watch the game. Sadly, that was not to be. RB had to put a central line in a preeclampic patient in L&D (never thought I'd have to see the inside of that place again), but after 3-4 tries he couldn't do it (the girl had a bad case of generalized edema; poor girl was in a lot of discomfort) so I paged BR to come help him out. To our surprise, JB came with him (he finally made it back to town). BR couldn't get the line in either, but JB got it in easily. Later he (nicely) reprimanded me for contaminating the sterile field by putting a syringe down on the blue sheet; I don't even remember if I apologized =(

The guys managed to catch a play or two of the Cowboys game (the OB residents were watching it in an empty room) before we had to go back down to the ER. More MVCs rolled in, and one patient (a nurse, it turns out) was flown to the ER after she got drunk and fell off a scaffolding. She kept yelling that there was nothing wrong with her and threatening to pull out her IVs; BR had to go in and get her to cool down. I then went to see a patient who had an unsuccessful I&D on an abscess on her butt; apparently whoever did it told her to leave the wound packing inside the wound for a week, instead of changing it twice a day, and the stuff was oozing pus. Really gross. It really hurt, too; she wanted to hit RB after he tried to peel the scab off to see how deep the incision was. At one point the Short Stay nurses tackled RB and tried to get him to see a patient who'd been waiting for about 8 hrs, so I was sent to talk to him before the ER attending handed me another chart. This man had a huge swelling around a hernia incision site that was non tender to palpation (rule out abscess?); JB later stuck a syringe in there and drew out blood. It was a huge hematoma. By this time the football game was over and both doctors and nurses were griping about how they couldn't watch the game and how it sucked the Cowboys lost.

I followed BB and JB on rounds, and in the ICU, JB asked me what the point of a Swan-Ganz catheter was. I forgot (I just remembered one prof's story about "floating a swan"), and I proceeded to get pimped on the different types of shock, CVP, PCWP, preload, afterload, etc. Some I knew, others I didn't. "You got to know all these well for medicine," said JB. "All right, that's enough midnight teaching." Whew. JB and BB retired to their room around midnight so I did the same (even though BR suggested I watch RB drain the "butt pus" I was exhausted) Because I don't have a trauma pager, I felt bad about sleeping through the night, so I set my alarm for 2 a.m. My timing couldn't have been more perfect; a patient was brought in after he slit his own throat 2-3 times (he owed someone money and needed a way out). BR said that he was originally going to wake me but let me sleep in, so it's a good thing I woke myself up. There was a police chaperone not far away as RB and BR cleaned the patient's neck and prepared to sew him up. They did the deep stitches while I did some of the surface sutures. There was also a burning smell in the ER b/c the nurses burned a bag of popcorn. At 4:30 a.m. we all went back to the lounge. I slept until 6:15, but the two interns barely had a chance to lie down before getting paged again. The morning went by in a blur but finally at 10:40 we were free to leave.

General Surgery: Shortstaffed at the Clinic

JB had to fly out of town yesterday because his dad was ill, so it was just BB, BR, RB, and me today. Normally on Clinic Days, we try to finish rounding by 8:00 a.m., grab breakfast at the cafeteria, and then go to clinic. I left RB on the 5th floor (where I had to recall some OB Spanish to interview a patient recovering from appendicitis) to get breakfast at 8:15, but no one else was there. So I went to the clinic at 8:30, but still, no one was there. But... there were five patients in rooms waiting to be seen, with the first room labeled 7:50! I've always hated making patients wait, so I paged RB asking if I can go ahead and start seeing patients. He got the OK from BB (now the most senior member of our team), so I went to work. The first two were lap chole followups (very straightforward), but the third was a man who needed an ileostomy reversed, and that required a physician's signature on the consent form. Fortunately by the time I finished talking to him the rest of the gang had arrived, and that made my job slightly easier.

Even still, RB was assigned to work with the neurosurgeon today, leaving BR, BB, and me to handle the general surgery cases. I never saw so many patients in one setting on my own as I did today. I had several lap chole follow-ups and also had to schedule new cases. One was an HIV+ man with rectal warts; when I presented to BR, the first question he asked was if he was HIV +. "One guy came to the ER once and asked how he got rectal warts," said BR. "Want to know what the attending told him? 'Buttf***ing.' " That's bluntness for you. What struck me as funny was that he chose to schedule his surgery for Valentine's Day, hardly romantic. The saddest case was one of our last patients, a middle-aged man with Stage IV adenocarcinoma of the lung whose vocal cords have become paralyzed. He needed a PEG tube inserted b/c he can no longer swallow and needs a trache to breathe. Any communication had to be written by hand on a notepad, and he wrote a lot about how his trache gets plugged up by mucus and his entire chest and abdominal area hurt from coughing and choking so much. It took a while for BB to assure him that the PEG will do wonders for his nutrition (the man was pretty emaciated) and pain control, since he can no longer swallow pain pills. The last case was a lipoma removal, but by the time we left the clinic, it was almost 3:00 pm.

I'm so glad I have tomorrow off...

General Surgery: Wednesday Call

Yesterday morning around 4:00 a.m. I got a voicemail from Corey (I'd heard the phone ringing but ignored it, dismissing it as a wrong number initially) saying that lecture had been postponed from 7 a.m. to 9 a.m. b/c our prof Dr. B had do perform surgery at 7 a.m. That's all fine and good except I (and the others, I'm sure) was annoyed at being awakened so early. Later Corey explained that the surgery office had called to wake him up and ask him to call everyone to let them know the situation. We have a "call tree" in which everyone calls 2 other people in case something arises, and Corey's name is at the top of the tree. Of course, the two people he was supposed to call never answered their phones, so he just called everyone on the list. Got to give him props for that one.

Because lecture time was shortened, Dr. B just talked about fluids (which I've never been good at). I made sure to eat a huge lunch before reporting to the OR, where JB and BB were in the process of removing a sebaceous cyst from a man's neck. There was a nursing student from OU watching the surgery, too; JB later said she was our attending's girlfriend's daughter (it's all about connections) I was wearing my own royal blue scrubs (got tired of the JPS ones), but that made people mistake me as a nurse (JPS nurses wear royal blue), so JB told me to at least tuck my scrub top in. "Nurses have pockets so they need to keep their shirts untucked, but you can't do that," he said. This isn't the first time that JB has tried to set me apart from nurses; one time I photocopied a prescription to save the nurses some time and he said my brain was made for better things than that. I jokingly told the student nurse (already forgot her name) that sebaceous cysts don't just look like cheese, they smell like it, too. She laughed, but maybe it was a weak laugh. Wanting to familiarize myself with the case, I went to read the patient's chart. Suddenly there was a loud THUD! and a rolling cart crashed into the cart that the chart was on. I looked up and found that the other student was passed out cold on the floor; when she fell she'd sent the cart rolling in my direction. Both the attending and the scrub tech immediately rushed to her side to make sure she was all right, but JB and BB stayed where they were (they were sterile) The scrub tech had to scrub in again because he got contaminated when he went ot check on the student. Later we wondered what had made her pass out. Someone suggested the sight of blood (not likely), and another nurse said maybe her knees were locked. Someone else joked that it was because the nurse went to OU ("Those Oklahoma people...) RB did attend OU for med school so he was slightly annoyed when I related the story to him later. The patient also had little clustered masses on his head, so my residents essentially cut out a chunk of his scalp for biopsy. And the way the scalp sample was cut, it was slightly mouse-shaped; you could make out the pointed nose, and there was a round whorl of hair that could easily pass for an ear. JB got excited and said it was things like this that made surgery fun, even going so far as to give it a thread tail when one of the nurses said it lacked a tail. When the surgery was over, the patient send out a spray of urine when the catheter was removed, and one of the nurses went ducking for cover. "It was coming right at me," she said. That was a close one then.

The second surgery after that was a diagnostic colonoscopy for a woman complaining of rectal pain and bleeding; she couldn't even tolerate a DRE in the clinic. The PCP she saw called it "hemorrhoids). So we put her to sleep, but one took at her perianal area made everyone groan/scream. It looked, in JB's words, as though someone took a shotgun to her anus; there was no sphincter, just an ulcerating hole, and within that hole was a rock-like mass. Looked like cancer to everyone present. The colonoscopy itself was unremarkable, so it hasn't spread beyond that region yet. Later JB went to tell the patient's daughter-in-law the diagnosis, and the daughter groaned. "I knew it," she said, saying that her mother-in-law was the type of person who smoked and drank all the time and never went to see the doctor until things were too late. It didn't help that the daughter-in-law was 35 weeks pregnant and can't take care of both a baby and the patient at the same time; they'll have to think of something. I saw Ilona near the OR; she got to intubate a patient today during an OB procedure. "You got to intubate?" I asked. JB (who was Ilona's resident also) spoke up, "She's interested in anesthesiology."

All surgeries were done by 4:00 pm, so I went to find the ICU to see what I could help the others with. Sometime later there was a STAT trauma call to the ER: GSW victim, CPR in progress. "Do you know the survival rate of patients who receive CPR outside of a hospital?" asked JB. No, I didn't. "1%." That low?! Anyways, we all rushed to the ER, and while there were already tons of people in the room, I got suited up anyway, just in case. They brought the man in, and everyone immediately tried to improve his volume. He had about 2-3 IOs put in; RB did one and said it felt really cool. Next JB opened his chest along the side to give him open chest CPR, at one point putting spatula-like chargers into the chest to give him a defib shock. "Shocking!" someone called, but it did nothing. To my surprise, no one tried again. "That's it," said JB. "Time, 16:48." There were several young nurses gathered around the body, so JB pointed out the lung, omentum, and other organs through the chest incision (I was shoved too far back to see anything). As I got closer and saw the lung (speckled black from years of smoking), I touched it and was surprised by how cool it already felt. The man's limbs, too, were white and already cool. Because this was a crime scene (he pulled a gun on a cop who then shot him), his clothes were collected and his hands were covered with bags for evidence before he was placed in a body bag to be taken to the ME's office. RB had to write a report on him, and he asked me if the patient's feet were pale. Yeah, they were.

After that trauma, RB sent me to look at an HIV+ patient's perianal abscess. The patient was pleasant enough, but I was reminded of his HIV status when his nurse came in wearing a mask and gloves. Even though we know that HIV is bloodborne, when you see someone protecting themselves like that, sometimes you can't help but worry. I saw my patient at 6:00 pm, but it was a good 3 hrs before RB could follow up on him. My gastric cancer patient was wanting to go home so RB needed to talk to her family, and then he had to talk to another patient's family (about 6 family members) so we kept getting behind schedule. RB confirmed the HIV patient had an abscess and after presenting to JB (who came out of an elective vascular surgery and was ready for bed), RB and I got a 10:00 pm dinner at McDonalds (cafeteria was closed and my money was in the call room) We then went to drain the abscess, but all that came out was blood, no pus. After we finished with his wound, it was around 11:30 and surprisingly, for the moment, we were done. RB and BR hung out in the lounge watching football while I went to the call room to sleep. I woke up around 4:00 a.m. and checked the pager (no pages) before sleeping again until 5:30. When I went to the lounge, RB and BR were sleeping exactly where I'd left them. I wondered at first if they got no pages all night, but that wasn't the case. They still had a few consults, but luckily no traumas.

I rounded on a few patients before going to the family clinic for "Christmas" and ran into my residents en route to do an endoscopy/colonoscopy. This was a routine procedure, no polyps seen. After that, we rounded with the attending on call, Dr. T (whose girlfriend's daughter passed out in the OR) before getting dismissed around 10:00 a.m this morning. All in all, not too bad. At least I got some sleep. And tomorrow is a whole day of General Surgery clinic. *sigh* That's going to be tiring.

General Surgery: PEGs

Today was a pre-call day (and JB had 2-3 surgeries scheduled), so after rounding on patients I went to the OR to see if the surgeries had begun yet. As it turned out, JB couldn't do his first surgery (VATS, video-assisted thoracostomy) until the vascular surgeon, Dr. A, put in a pacemaker on another patient first. So I hung out in the call room and then followed RB on rounds for a while before the two of us went to the OR and found the patient being prepped for surgery. Then RB left to take care of floor patients while JB and I scrubbed in.

The patient, SP, was an African man who had a leak in his left lung secondary to bleb formation(s) that landed him at JPS with pneumothorax. Our goal: enter the chest laparoscopically, find that bleb, and help SP breathe better. SP had smoked for years and a good portion of his lung was actually stuck to the ceiling of the chest; those adhesions were removed with relative ease. It was interesting watching the lung inflate and deflate with each breath after the adhesions were removed and the lung was no longer stuck. JB then filled the chest cavity with saline to find the bleb ("Look for bubbles with exhalation") Sure enough, we saw what could easily pass as a bubbling geyser on the medial side of the lung, but the bleb was nowhere in sight. It didn't help that the saline was mixing with blood, making visibility even worse. Dr. A came in and couldn't find the bleb either, and with an exasperated sigh he said that they might have to operate by opening the rib cage instead of just working with the laparoscope. Then JB was called away to fill out consents and paperwork on the cancer patient we saw yesterday (whose surgery was after this one), and Dr. A immediately flushed the chest with saline to see if he could find the elusive bleb. My job was to hold the camera, and suddenly, there it was. The bleb looked like a long "proboscis-like" piece of flesh (Dr. A's words, not mine) with a round tear in the tissue, and Dr. A handed me a laparoscopic stapler and told me to cut it out. "Come on, let's get this done before [JB] gets back," he said. "He'll be sorry he missed this one." Under Dr. A's instructions, I snipped the bleb in half, just in time as JB reentered the ER. "Sorry, we're all done! Your med student saw the bleb and took action, I couldn't stop her," said Dr. A. JB didn't bat an eye, just replied, "That's good, I've been trying to get her to talk for a week." At any rate, JB finished up by capturing the bleb with laparoscopic forceps and pulling it out. Fortunately that was the only bleb, and SP emerged from surgery with no complications.

Immediately after we finished the surgery, we went next door where the other patient was waiting. She needed a MediPort put into her chest (for chemo treatments) as well as a PEG feeding tube (radiation treatment to larynx muscles makes swallowing difficult, so she'll need a PEG tube throughout her treatment). PEG is short for The doctor sticks an endoscope down the throat to the stomach, then wires a thread into the stomach through a stomach incision. The endoscope attaches to the wire and pulls it through the esophagus up to the mouth, where the PEG tube is sewn on and then transferred via wire back to the stomach. It's a fairly interesting surgery, and it was cool watching the peristalsis in the small bowel. We also found a small polyp in the woman's stomach (possible mets?) and biopsied it; we also saw an ugly white patch on her throat that had to be her cancer. The port insertion was uncomplicated also, except when the central line went up the internal jugular instead of to the IVC (confirmed by on-site X-ray).

By this time it was very well past noon and I was getting fairly hungry, but JB immediately went to ICU where he was scheduled to do another PEG and tracheostomy on an ICU patient. Somewhere around 2:00 I couldn't take it anymore and told JB I was going to the bathroom. That was partly true; I also ran back to the call room and gulped down a NutriGrain bar so that I wouldn't feel so hungry. I followed JB from around 9:30 to 4:00, and I never saw him eat anything. Don't surgeons ever get hungry? I understand the need to get through as many patients as possible, but surely people need to take time to eat also? Of course, certain people will say that all I think about is food, but I'm used to eating at regular intervals. That has never happened in surgery; I have to carry food with me and eat at opportune times.

The ICU procedure was a waste of my time b/c JB was training one of the FP residents to do a PEG. He kept getting paged by the OR for another procedure, and at one point I asked what to do. Dr. K (who was watching the procedure) looked a bit exasperated and told me to go outside and return the page to see what was going on. *sigh* Some things never change; even back in obgyn Dr. K thought I was too timid for my own good. Since I was reduced to watching, I got bored and nearly fell asleep on my feet. After that we returned to the OR and I watched as JB taught the FP resident how to put in an IVC filter, but after that...another PEG and tracheostomy. At 4:00, after he finished the IVC, I asked if I could take off early. (Nothing else for me to do, after all). Fortunately JB let me go.

I've had three regular patients in Tele East. One was a man with a spinal contusion; another was a man who, along with his wife, got hurt when an 18-wheeler hit their car. His wife was in ICU until today, and now she's been moved into his room. He's happy that now he can just look across the room and see her now. My third patient was a 28-year-old woman who had a Roux-en-Y gastric bypass after she was diagnosed with gastric cancer (big shock right here, since she's so young). She'd been making a lot of progress (eating solid foods, graduating from a feeding tube to no tube at all), but today she fell ill with severe LUQ pain. And now radiology says that more than half of her abdominal lymph nodes test positive for cancer. =( It's just so sad.

Another call day awaits me tomorrow =( Fortunately (sort of) I have lecture in the morning, which will be a break from the OR. My feet are killing me after standing for so long, I hate to think what tomorrow will be like. And of course, I need to load up on snacks.

General Surgery: Hernias, Staples, Stitches, and Fibroadenomas

This morning I started off at Tele East as usual and saw a patient who was hospitalized for pericardial window surgery to help her breathe better (she had metastatic lung cancer). When I talked to her, she griped about how she couldn't stop coughing, and I said it was probably due to her many years of smoking. Wrong thing to say. She gave me a dirty look and said that had nothing to do with it. She also demanded to go home b/c she needed to take care of her children. BR saw her shortly after I did, and when he left the room (I heard her arguing with him), he said, "I don't think she likes me right now." After we left Tele East, I went to Tower 6 and found RB, who sent me down one floor to 5. There I ran into the Surgery D team (my team is Surgery B) and saw Dr. P from ob-gyn. The last time I saw her she was 35 weeks pregnant; today I asked about her baby and she said he's doing very well. After seeing the patients on 5 (including the girl with the hand fractures), I went to meet the rest of the team at the cafeteria and ran into Dr. D, my 2nd year ob-gyn resident. I asked her who was on green team this month (Garrett and one of the Kathys) and when she saw that my resident was JB, she said, "Oh, he's good!" Glad to hear it; I'm going into surgery with him tomorrow.

I will never understand why the surgery clinic starts letting patients into the rooms at 7:30 a.m. when the team doesn't even arrive at the clinic until 8:45. I saw a patient who had that 7:30 appointment b/c he was scheduled to have a hernia repair that was cancelled just before he was about to be put under b/c he had an episode of acute pancreatitis a few weeks prior. His hernia was huge (10 cm diameter), causing him lots of pain and discomfort, and he asked if he could get surgery done ASAP. I presented his case to JB, and he scheduled the surgery for ten days from now. Another patient was a friendly AA man who needed a colonoscopy to determine the site of a GI bleed (he was severely anemic and had dark tarry stools), but because I couldn't get ahold of JB or BB in time (he had to leave to take his wife to work), he went ahead and left the clinic. I told JB about him anyway, and commented that he was on a liver transplant list for liver dz. "Liver failure?! Did he have ascites?" asked JB. If he did, it wasn't very obvious, but he did have gynecomastia. "Well, there you go!" said JB. A third patient I saw had severe left flank pain from a hernia repair that apparently didn't work, and a fourth had an inguinal hernia (what's with all the hernias?!) Sometime around 12:30, all the residents except JB went to a mandatory meeting. We still had five patients left so I was freaking out a little, but JB made my job easier by telling me to remove the staples and sutures from one patient while he sees the others.

My patient was an amputee (he lost his leg to gangrene) with a long row of stitches along the stump of his knee. I originally asked him to lay his stump on a stool, but there was a good deal of scar tissue overlying the stitches, so when I pulled those out, sometimes he'd yell (though he was nice about it), and if that happened I'd take a break from the so-called torture. Later RB came in to see how I was doing (I was still pulling sutures out after JB saw all the patients), and helped me remove some of the more difficult sutures. This time he held the patient's stump in his hand while removing the stitches, and this time there was no pain at all. The patient and I were both surprised; we concluded that the difference in pain was probably due to the way his knee was placed (flexed vs extended). The staple removal went without a hitch, and after the patient left it was 1:40 pm. I still hadn't eaten lunch (sneaked a granola bar between patients so I wasn't too hungry), so RB told me to get some fajitas from the surgery conference room. JB was there too, so I got some one-on-one face time with him. He said I've been doing well so far (showing up on time, writing a decent number of notes), and said that there are many ways people approach surgeries. BB, he said, was still inexperienced in many procedures and a bit on the shy side, while BR has to be held back with a leash/rein because he loves operating so much. I wonder what kind of surgeon I would be. After going through the schedule we decided that I'll get my non-call weekends off. Works well with me =) I really think I have Dr. K to thank for showing me and Anita how to write decent notes back in ob-gyn; it's paying off.

The afternoon was spent at the HCW Breast Clinic (JB didn't have to go; he called it the perks of being a chief) seeing patients with breast cancer or breast masses. There I ran into another familiar face: Dr. G, the ob intern from my ob-gyn rotation. Just like that, I've seen almost everyone from the old Green team except Dr. C (the chief) and Dr. B (the 2nd year FP). There were too many people at the clinic (only 4 exam rooms), so BB gladly took his leave and left 3 interns and a med student to see the patients. I accompanied RB to rooms as a chaperone but also got 2 patients of my own. Their cases were exactly the same: follow-up on two young women who each had benign fibroadenomas removed. Fortunately that meant I wouldn't take up too much of the staff attending's time; we were in and out of the room in a matter of minutes (to his credit, BR finished seeing his patients before me, but let me present first b/c he knew my cases were shorter). RB saw one patient who wanted to remove both breasts (she was diagnosed with Stage 2 cancer) and wouldn't be talked out of it; the attending was in there with her for a good 30 minutes at least. *sigh* Well, BB and BR have tomorrow off; so it'll be RB and me doing rounds at first, and then I can go to surgery with JB. That means I'll have to eat a nice big breakfast so that I don't get hungry in mid-surgery *sigh, getting fat*

General Surgery: Saturday Call

*This entry encompasses a 26 hr day spent at JPS starting yesterday*

On weekends, call doesn't start until 9 a.m., so from 9-12:30 we rounded on patients. Somewhere in that time I stopped briefly by the lounge to page one of my interns (with a four-man team, it's way too easy to get separated) and saw David H and Dina there; the two of them were on call for medicine. Their medicine resident warned me to expect lots of trauma cases to come in today. I asked why, and he said, "It's a Saturday, and the weather's nice." Great...

After rounding on patients during weekend call (I have three patients on Telemetry), the job of the trauma team (the surgical team on call) is to see trauma cases in the ER or do surgical procedures around the hospital. First I stayed in the ER with RB. There were too many MVCs (motor vehicle collisions) to count. One man was hit from the right by another driver (who didn't make it). A 21-year-old guy (who looked an awful lot like Corey so I did a double take when I saw him) got pinned by the dashboard when his friend accidentally drove off the road and crashed into some trees (car was totalled). A Harley Davidson biker in his 60s got pushed over by a combination of gravel and wind and broke 8 right ribs and tore the glenoid region of his shoulder; the ortho resident offered to take his case, which was a surprise since ortho, according to RB, usually doesn't take action until the trauma team pushes them to do it. A woman who wasn't wearing a seatbelt got a HUGE bruise on her knee and couldn't dorsiflex her foot afterwards; we all wondered what was going on with that.

After a while ER got a little boring (my job was to do H&Ps on patients and give them a physical) so I went to find BR (he was removing a bullet from a John Doe who got shot 5 times and I wanted to watch). When the bullet was extracted, we saw bits of clothing fiber attached to it; obviously it came from John Doe's shirt after he got shot. BR had to keep the bullet (located in a specimen cup) until FWPD contacted him, but they never did, and he has to keep that bullet with him at all times until they do. It'll be interesting to see if he still has that bullet tomorrow. Afterwards, we went to do a central line on a homeless guy who got hit by a car while he was crossing the street while intoxicated (yet the woman who hit him got off free and he got reprimanded for being drunk). He needed a CL b/c he had bacteremia, and b/c he rolled over in bed a lot, arm IVs kept getting ripped off. When BR went to talk to him, he kept talking about how he felt he should be compensated for all the suffering he's endured and kept asking us over and over for more pain meds. Apparently one Lortab every few hours wasn't doing it for him, and he asked for morphine. He even asked BR to call the nurse to the room and tell him to give the patient stronger Lortab. Some profanities were spoken, but BR ignored it and did a successful CL. He came close to losing his temper on the patient after the 20th time he asked for more drugs ("Don't ask me that again!") and said that if the patient wasn't being such a little b**** he would have let me do the CL. Later we inserted a chest tube on a stroke victim in the ICU who kept fighting the procedure; a student nurse had to hold him down. There, I met Thomas, the ICU respiratory therapist, who encouraged me to ask him any questions I had about patients breathing problems. That came in helpful this morning, when one patient had a pleural rub and I didn't know what sound that was.

After that, I went to a room where JB and BB were doing a PEG/tracheostomy (I still don't know what PEG is) with the attending on call, Dr. G. Dr. G asked me if I've ever done a "bronch" (bronchoscopy), I said no, and he offered to teach me. Basically, a bronchoscope is a very expensive little toy ($25,000) that looks like a larger version of the Wii nunchuck. There is a button to move the tip of the scope up or down, and you center the view of the scope by rotating your hand. You also have to keep the end of the scope straight at all times if possible; excessive bending would only destroy the fiberoptic nerves in the scope. I enjoyed it until JB started pimping me on what part of the lung I was in. Making my first big blunder of the night (my brain and mouth don't match up) I asked if I was in the esophagus b/c the word "trachea" didn't come to mind in time. Great, nice one. Then I was asked the distinctive names of each bronchus in the right lung, which I did not remember from anatomy. *sigh* Later JB told me that he wanted me to help the interns do procedures when I'm in the ER (i.e. suturing, Foley catheters, etc) I had a perfect chance to do a Foley when paramedics brought in an unconscious guy who'd been choked (it was Level 1 so BB and JB were awakened and paged from the call room), but someone beat me to it. And as for suturing, the Corey look-a-like had bitten a hole through his lip during the impact, requiring 3 layers of suturing, and the medicine intern doing her ENT rotation had to do it even though she said she didn't trust her suturing skills. JB let me watch a CT scan on a 2 wk post partum Jane Doe who had been found lying in a ditch, and the ICU team (with Dr. K from obgyn) was there, too. Dr. K was hoping to hand one of his patients (who had an abscess) to the surgical team, but JB burst his bubble by saying it was nothing ICU wouldn't handle by themselves.

As Dina's resident predicted (I saw her a few times around midnight in the ER), the traumas didn't stop coming in. One lady got pushed over and landed on her head (possible subarachnoid hemorrhage) and she could not stop throwing up stuff that looked like egg drop soup (I checked on her during rounds this morning and she felt much better). Another motorcycle victim came in and required debridement on many of his wounds (this was compared to the other biker who had relatively little external damage). RB, BR, and I didn't officially eat dinner until midnight (I made it that far by taking quick trips to the call room and eating oranges and granola bars I'd brought from home) My interns don't really care what I do, but they didn't want me to stand around doing nothing either. At 2:30 a.m., there was a lull in the ER and RB told me to get some sleep. Easier said than done; I tossed and turned in the call room for an hour before getting some semi-sleep. Knowing that we start rounding at 6:00 a.m., I set my alarm for 5:30 and met with my team back in ER. Then I saw BB down there (he's the 2nd year) and BR told me that after I'd left, four traumas arrived in a matter of minutes. I felt bad that the interns weren't able to sleep at all (I'd given RB my pager number but he was too busy to page me), and I felt very useless for a good part of the morning in the ER.

Around 7:00 a.m. I started rounding on my telemetry patients as well as two patients we'd admitted into the ER. I went to check on John Doe but JB and Dr. G came in so my visit there was for nothing (JB was rounding on patients and wrote notes on the ones he saw). I returned to the ER to see RB interview a 17-year-old who was in a MVC (seeing a pattern here?) and lost almost all the skin on the back of her left hand. I wondered where all her blood had come from, and when RB uncovered her hand, you could see torn tendons and flesh. She wanted to see her wound, too, and to her credit she didn't pass out or scream when she saw how bad it was (it was fractured, too). Her right hand had a fracture in the most distal part of her middle finger so that was immobilized pending an ortho consult. Not long afterwards, a middle-aged woman was brought into the next bed, combatative and screaming. She kept begging the doctors not to stick her, asking what they were doing to keep her alive, and screaming, "Father! Jesus, help me!" After doing my psych rotation, I was fairly sure her mental status was altered, and told the teenage girl with the broken hands not to let the screaming bother her. "Can you tell [the screaming patient] that there's nothing to be scared about?" she asked. I was very impressed with her maturity and thoughtfulness considering how she was injured, too, and I told her that while I could try, the way the woman is now, it'd be hard to get through to her.

Afterwards I lost RB and ended up paging BR asking me where to go next. He told me that JB had already gone home for the day and that I could leave to. Dr. K came by just as I was confirming that I could leave, and he said, "Go home. Tell them I said you could." Nice try, Dr. K, but you're not my resident anymore =) He also commented that ICU had more admissions last night than they could handle, saying that his team worked harder than ours (friendly rivalry between ICU and trauma). I don't doubt it. After I finally got home, I went to sleep for about 3 hours. Both feet are killing me (my Klogs are failing me), and I can't even imagine how tired the interns had to be. And it all starts again tomorrow.

General Surgery: The Fem-Fem Bypass

This morning I went to JPS at 6:30 a.m. to help BR see some patients before going to lecture. I saw three patients in Telemetry East before BR caught up to me. I asked him which patients hadn't been seen yet, and he said, "All of them." Apparently while I'd been looking up patient data and talking to them, he'd been chatting with other doctors at the nurses' station! *sigh* Lecture was wasted on me; I couldn't stop yawning in class (at one point I dozed off). It made no sense for me to be so tired since I wasn't even on call last night (Amar was, and he stayed awake pretty well). I treated myself to a long lunch break and a green tea latte before driving back to JPS (only Dustin and I went back; Amar was post-call and Phuong got the afternoon off). I found BB in the OR and he let me scrub in with him for surgery. The assigned procedure was an axillary-femoral bypass/femoral-femoral bypass, which involved inserting a graft that ran from the axillary artery to the femoral artery (yes, it would run along the entire length of the body), and then inserting another graft that connected the two femoral arteries by running above the pubic bone. This sounded intimidating, but word was passed down from Dr. A (the other vascular surgeon) that he hoped to only do the fem-fem bypass. That would decrease the total surgery time by an hour or two, which sounded good to everyone.

The patient, an overweight woman, had her entire body painted with an iodine substitute, but even after we were all scrubbed in and ready to go, we had to wait nearly 45 minutes for Dr. A to arrive b/c he was doing an angiogram. This was BB's first time doing such a procedure (he's a 2nd year resident) so he wasn't even allowed to make the first cut. That honor went to Dr. A. The first thing to do was find the femoral pulse, which was hard because the woman had both occluded arteries and excess body fat, not a good combination. At one point Dr. A asked the anesthesiologist how much the woman weighed, and he replied, "100 kg." To this, Dr. A said, "She does not weigh just 100 kg." Dr. A and BB had to make incisions at least 2 inches deep in order to reach the arteries, and Dr. A had to keep using a Doppler to find the pulse. In this manner, it took up to 1 hr alone to find the arteries (which were "small" compared to her body weight).

Once the arteries were found, Dr. A made a slit up the left femoral artery and removed a white plaque that was lining the artery. Even still, he said the occlusion was not too bad; it was less than 90% so blood still flowed through. Then he sewed a Gortex graft (looks like a long white tube) to the left femoral artery, made a tunnel above the pubic bone with his fingrs, looped the graft to the opposite side, made a slit in the other artery, and sewed the other end of the graft there. Then the incisions were sewn and stapled (I only got to do the stapling; this reminded me of my OB days). The surgery took about 3 hrs to complete, and that was just for the fem-fem bypass alone. And after seeing how heavy the patient was, Dr. A said that he probably would have had lots of trouble doing an axillo-femoral bypass since there was so much tissue to work with, and we were all grateful that all the patient needed was a fem-fem to restore her pedal pulses. BB let me put my fingers on the graft to feel the blood pulsing through it; pretty cool. I was fairly sore and hungry by the end of the surgery, but BB had been NPO all day (and the surgery ended at 6 pm) so I didn't complain.

Tomorrow I'm on call =/ We'll see how it goes.

General Surgery: Clinic

This morning after a trauma conference (where we talked about the death of a patient after a MVA in which her spine was broken at C4; one of the attendings said that if he had such a fracture death would be preferable since you can't breathe on your own if anything above C5 is damaged) I met the rest of my team. Funnily enough, there are B's in all their names: JB, the chief; BB, the 2nd year; BR, the gen surgery intern, and NB, the ortho intern. And I'm the only female of the bunch (actually, there was only one other female aside from me at the conference; surgery really does have a shortage of women) So needless to say, I often feel awkward with my team.

Today clinic started at around 7:45, but we didn't even make it to the clinic until 8:30. I also got very lost in the clinic area (heck, I lost the team after they left the conference b/c they were walking so fast) because it's shaped like an infinity symbol, and the halls are so narrow it's easy to get lost. In the morning, we saw general surgery cases; in the afternoon, we saw vascular surgery cases. At first it was just me, JB, and BB, so it took us a long time to get through the patients. Once NB and BR returned from rounds, however, things moved a lot more quickly. One patient I saw had all the finding of cholecystitis except she was young and had a clean ultrasound; she was also under lots of stress so JB attributed her symptoms to GERD and psychosomatic stuff. Another guy got shot through the suprapubic region and had to wear a colostomy bag b/c of rectum injury; now he's hoping to get it taken out. I got to see the colostomy bag; the "feces" inside it still had lots of liquid so it didn't look too gross. We didn't leave for lunch until 1:25, and by 2:00 it was back to the clinic.

Vascular cases are tougher b/c it's hard to gauge exactly whether the patients need surgery or not (and sometimes the patients themselves don't know what to do). One lady came asking if she was in danger of dying b/c ER doctors had told her that she had an aneurysm in her RCA; in reality, she'd undergone thrombectomies in both common carotids so both of her carotids have a wider diameter than usual. Another man had to get a clot removed from his fem pop bypass, and the wound had become infected. It was now healing by second intentions, and while it looked a bit nasty the drainage was clear (not pus-filled). The vascular surgeon, Dr. S, was present, and he looked young. At first I thought he was a resident =P Tomorrow we have class, but when JB said to remember to stop by tomorrow after classes, I said, "Well class doesn't start until 9:00 so I can come earlier." JB looked impressed and said most of my classmates wouldn't share that sort of information in order to sleep in, and of my willingness to come in early he said, "That's what we like to hear." So am I an idiot for working more hours than necessary?

*sigh* Today was exhausting, and I didn't even do any surgery. I'll probably get to see and scrub in on a few cases tomorrow, but seeing how we didn't have scrub clinic, I expect I'll make an idiot of myself tomorrow. =/

General Surgery: Day One

This morning we surgery people had to report to the 5th floor of the PCC for orientation at 7:00 a.m. before going to our respective hospitals for our first day of work. Amar, Dustin N, Phuong, and I were starting out with 4 weeks of general surgery at JPS, and we were joined by Annie and Lauren O for 2 weeks of ortho, also at JPS. There, we picked up our badges (same one I used for obgyn), parking decals (the parking lot smelled an awful lot like fecal matter), and scrubs. I don't like these scrubs; they're so new they chafe my skin. After that, the four of us went to the call room and took turns calling our surgical teams to let them know we've arrived. I was assigned to team B, which for some reason has seven residents this month, and was called to the ER to follow a 4th year resident and an ortho intern, Drs "Burberry" and "Bell," or B&B. (I'll just call them JB and NB). Dr. JB seems like a laid-back, sarcastic (self-proclaimed), and overall cool chief resident; he made it clear from the start that surgery would be a lot of fun. A lot of nurses seem to like him b/c he' s fairly good looking, but sorry ladies, he's married with 3 kids. ;) His wife went to med school with him, but never went to residency in favor of being a stay-at-home mom; I thought that was interesting.

According to Dr. JB, my job as a med student is to help Dr. NB (intern) as much as possible except when there are surgeries to observe and assist in. This meant...progress notes. After seeing a new notes I had a general idea of what Dr. NB wanted (it wasn't too different from the OB post-op notes), so I felt fairly comfortable writing notes on my own in little time. Dr. NB was post-call so he yawned a lot as he wrote his notes (luckily for me my team was post-call today so I don't have call until Saturday). I rounded with him until about 1:30 and then we met Dr. JB for lunch in the cafeteria. After lunch, Dr. NB went home to sleep while Dr. JB rounded on all the others. I think I can get a workout at JPS just from trying to keep up with Dr. JB; the man walks fast. He didn't always explain where we were going so I often had no clue where we were. Along the way, I saw several classmates doing their medicine rotations (Dina) and psych rotations (Justin) as well =) Then I ran into Dr. K (from obgyn) in the ICU; he and another resident were taking care of two fourth years. We exchanged hellos.

Most of the patients I saw today were in motor vehicle accidents, so I saw several broken femurs and broken arms. One fifteen-year-old girl had sustained brain damage in her car crash and was in a semi-conscious vegetative state when I saw her; it was really sad. In non-MVA related cases, one lady had gastric cancer and had a Roux-en-Y gastric bypass after her stomach was removed. Another man got shot 5 times (I'd like to know where that happened so I can stay away from there) by an unknown assailant. All in all, very interesting cases. Tomorrow morning I have to attend a trauma conference at 7:00 a.m., so I asked Dr. JB what time I should show up tomorrow. His reply: "Set aside enough time to see at least half the patients." Okay, but what time? Then I asked where I should meet him and the other residents; again, he didn't give me a specific location. I'm more used to the structure of OB so this was very different for me. My plan: arrive at 6:00 a.m., start on the top floors, and work my way down.

My one gripe with surgery so far: I'll be on call for my birthday =(