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.