So, I'm all moved into my new place and have spent the past two days participating in (well, mostly skipping) the usual onslaught of social "orientation" activities most schools nowadays organize before the first day of classes. I've met a few of my med school classmates, but honestly, I'm not too interested in making friends. My goal here is to get in and get out, diploma in hand, preferably with decent grades.
I took a tour of the campus this morning and everything felt familiar, although it has been over four years since I've seen any of the academic buildings. I learned that if one were to attempt to gain entry or exit from the gross anatomy lab without swiping their ID card, an alarm will sound and (if exiting) one will be locked inside the lab. In fact, that exact incident happened during our tour, and several students looked rather uncomfortable. I couldn't blame them; looking at all the dissecting tables with the cadavers safely ensconed in shiny white plastic bags, the faint smell of formalin and phenol in the air - it's enough to creep anyone out. Everyone says that the weird feeling passes within a week or two, and I believe it, but getting to that point is surely going to take a bit of adjustment.
Perhaps it's the unfamiliar environment, but I've caught myself longing to pack it all in and return home. I've even been thinking fondly of my college experiences, even though I know many of those times were not the happiest. I suppose once classes begin I won't have the time to ruminate so much on this loneliness.
Thursday, August 20, 2009
Wednesday, August 5, 2009
Triumphant return!
...Or something. Med school starts soon, so I thought I'd put it a pre-first day post, if you will, before I'm too swamped with work to remember that in a former lifetime I blogged frequently.
I move to campus two weeks from today and classes begin the following Monday. It's still far enough in the future that it seems removed from reality, but all the same I'm experiencing that familiar mix of anxiety and excitement which accompanies most major life changes. I've ordered my books and my stethoscope and come close to paying my tuition bill, though if I wait much longer on the latter I'm going to end up incurring late fees, so I expect to have that taken care of in the very near future.
Things are probably going to move quickly for the next 14 days. I'm trying to enjoy my last few moments of freedom by being exceptionally lazy (except for forcing myself to go to the gym daily so as not to gain an obscene amount of weight from a combination of slothfulness and overindulgence in delicious-though-very-calorie-dense desserts).
Anyway, there isn't much else to say other than reassure everyone that I haven't fallen off the face of the planet and that I will attempt to update this thing every so often in the coming school year, as my study schedule permits. Peace out for now.
I move to campus two weeks from today and classes begin the following Monday. It's still far enough in the future that it seems removed from reality, but all the same I'm experiencing that familiar mix of anxiety and excitement which accompanies most major life changes. I've ordered my books and my stethoscope and come close to paying my tuition bill, though if I wait much longer on the latter I'm going to end up incurring late fees, so I expect to have that taken care of in the very near future.
Things are probably going to move quickly for the next 14 days. I'm trying to enjoy my last few moments of freedom by being exceptionally lazy (except for forcing myself to go to the gym daily so as not to gain an obscene amount of weight from a combination of slothfulness and overindulgence in delicious-though-very-calorie-dense desserts).
Anyway, there isn't much else to say other than reassure everyone that I haven't fallen off the face of the planet and that I will attempt to update this thing every so often in the coming school year, as my study schedule permits. Peace out for now.
Saturday, April 25, 2009
Hiatus.
Well, the semester is drawing to a close, and I have no more shadowing days scheduled - just two presentations and a research paper to get through before I'm done (!). As I doubt there will be much medical stuff going on in my life this summer, I will pause these blog entries for a bit. Check back in late August for my first med school impressions; until then, thanks for reading.
Monday, April 20, 2009
ENT.
Today I shadowed an otolaryngeal specialist. It was a fairly interesting day due to the diversity of cases.
Most of the patients we saw in the clinic had some sort of cancer, though I'm not sure if that is representative of the specialty as a whole, or whether it just works out that at our clinic, the physicians see the more complicated cases and leave infected tonsils and other peds-type things to the PAs.
One middle-aged man with a history of sleep apnea was told he had Barrett's esophagus, a precancerous condition caused by chronic acid reflux disease. His voice was extremely hoarse, even though he had previously undergone some sort of surgical procedure to correct the apnea.
An otherwise-healthy 36-year old female was in for a two-week follow-up appointment for her total thyroidectomy. Her scar was healing nicely with no signs of infection. I learned that unlike most other cancers, thyroid cancer may involve lymph nodes and still be classified as Stage 1 (the best prognosis). In this woman's case, her biopsy showed three positive lymph nodes, but she was essentially cancer-free following the surgery.
For the two or three patients who had various forms of throat cancer, Dr. F passed a fiberoptic camera through the nose to inspect the vocal cords. This was particularly cool because they gave me a teaching scope to attach the to real one so that I could watch as the doctor did the procedure. One woman who was complaining of a sore throat had a yucky white mass of mucus sitting directly on her vocal cords, which explained her hoarseness.
The final patient of the morning had undergone a total laryngectomy a few years back, and used one of those creepy robot-voice amplifiers to speak. The voice nearly made me laugh at first, but I found that after two or three minutes listening to her talk I didn't notice it as much.
In the afternoon I was sent up to the OR to watch procedures. Unfortunately, two of Dr. F's three patients ended up canceling, so I was only able to watch one nasal septum repair. The procedure was extremely fast - I doubt the patient was asleep for longer than 20 minutes, though she was fully intubated. Dr. F first cut through the mucosa on the right side of the septum to expose the cartilage and bone, then cut away what appeared to be a large bone spur which was disfiguring the septum. He then punched a hole through the middle turbinate and drained some of the fluid inside. The turbinate drainage was repeated on the other side. Finally, he cauterized the incisions (the patient only lost about 20 cc, so there wasn't a whole lot of bleeding to control anyway), inserted and sutured splints into either side of the nose, and rechecked the surgical site with a fiberoptic camera. It was a fun, short procedure.
Since there were so many cancellations in the afternoon, I was invited back to watch some longer procedures. Lucky for me, the ENT team was in the middle of scheduling a patient for a very complicated radical neck dissection/laryngopharyngectomy, so as soon as they have finalized the date for that procedure they will let me know so I can watch. The way Dr. F explained it, it should be a pretty intense surgery (and long, too - at least 5 or 6 hours, probably more). Anyway, as the end of the semester approaches I should have some free time to pick some elective rotations, so if that surgery gets the green light then I will definitely try to scrub in. More OR time is always a good thing.
Most of the patients we saw in the clinic had some sort of cancer, though I'm not sure if that is representative of the specialty as a whole, or whether it just works out that at our clinic, the physicians see the more complicated cases and leave infected tonsils and other peds-type things to the PAs.
One middle-aged man with a history of sleep apnea was told he had Barrett's esophagus, a precancerous condition caused by chronic acid reflux disease. His voice was extremely hoarse, even though he had previously undergone some sort of surgical procedure to correct the apnea.
An otherwise-healthy 36-year old female was in for a two-week follow-up appointment for her total thyroidectomy. Her scar was healing nicely with no signs of infection. I learned that unlike most other cancers, thyroid cancer may involve lymph nodes and still be classified as Stage 1 (the best prognosis). In this woman's case, her biopsy showed three positive lymph nodes, but she was essentially cancer-free following the surgery.
For the two or three patients who had various forms of throat cancer, Dr. F passed a fiberoptic camera through the nose to inspect the vocal cords. This was particularly cool because they gave me a teaching scope to attach the to real one so that I could watch as the doctor did the procedure. One woman who was complaining of a sore throat had a yucky white mass of mucus sitting directly on her vocal cords, which explained her hoarseness.
The final patient of the morning had undergone a total laryngectomy a few years back, and used one of those creepy robot-voice amplifiers to speak. The voice nearly made me laugh at first, but I found that after two or three minutes listening to her talk I didn't notice it as much.
In the afternoon I was sent up to the OR to watch procedures. Unfortunately, two of Dr. F's three patients ended up canceling, so I was only able to watch one nasal septum repair. The procedure was extremely fast - I doubt the patient was asleep for longer than 20 minutes, though she was fully intubated. Dr. F first cut through the mucosa on the right side of the septum to expose the cartilage and bone, then cut away what appeared to be a large bone spur which was disfiguring the septum. He then punched a hole through the middle turbinate and drained some of the fluid inside. The turbinate drainage was repeated on the other side. Finally, he cauterized the incisions (the patient only lost about 20 cc, so there wasn't a whole lot of bleeding to control anyway), inserted and sutured splints into either side of the nose, and rechecked the surgical site with a fiberoptic camera. It was a fun, short procedure.
Since there were so many cancellations in the afternoon, I was invited back to watch some longer procedures. Lucky for me, the ENT team was in the middle of scheduling a patient for a very complicated radical neck dissection/laryngopharyngectomy, so as soon as they have finalized the date for that procedure they will let me know so I can watch. The way Dr. F explained it, it should be a pretty intense surgery (and long, too - at least 5 or 6 hours, probably more). Anyway, as the end of the semester approaches I should have some free time to pick some elective rotations, so if that surgery gets the green light then I will definitely try to scrub in. More OR time is always a good thing.
Friday, April 17, 2009
IM.
Yesterday I was assigned to follow one of the internal medicine residents. This particular physician was currently on the cardiology service, so we spent the entire morning rounding on about a dozen patients.
For those not familiar with academic medicine, perhaps I should explain how rounds work. At least once a day, a particular team of physicians and students will visit their patients, discussing what adjustments need to me made to the patients' medications, etc., and creating a plan for the next 24 hours or so. The ringleader of the circus is the attending physician, and his job is to guide the learning process by asking questions which may or may not directly pertain to the patients the team is treating - it's the Socratic method, basically. The resident doctors and med students attempt to answer the attending's questions while simultaneously writing orders, signing papers, and generally running around like chickens without their heads. If the attending is particularly nasty (or is just in a crappy mood), he will resort to what is known amongst students as "pimping," in which questions are asked in rapid-fire with the sole intent of making the student flustered enough to give a wrong answer. It's not a fun event to witness, and I don't care to think about being on the receiving end of that particular bit of unpleasantness in the future.
Anyway, because the resident was working with cardiology, our team consisted of myself, the resident, another resident, a medical student, and one of the cardiologists. This was a relatively small group; in larger hospitals there can easily be 10 or 15 people on a service. It took nearly three hours to get through all the patients, though only two were new admissions. Since I didn't have the patient list ahead of time, I didn't know much about the patients beyond the two-line blurb on the computer-generated list.
One female patient had pneumonia and bradycardia (slow heart rate). Bradycardia is treated with a pacemaker, but in this case, because she was had no cardiac symptoms, the cardiologist recommended that they skip the pacemaker. Her antibiotics were adjusted and she was told that as long as she could get up and walk around a bit, she would most likely be discharged the next day.
A middle-aged male patient was told that he needed a cardiac catheterization, which would be scheduled for the next day. His Coumadin (blood thinning drug) was halted and he was put on potassium, which reverses the effects of the anticoagulat. Generally, a patient who is about to undergo a surgical procedure is taken off of blood thinners to prevent them from bleeding out. Coagulants can be given if an emergency arises, but those drugs can cause unpleasant side effects, so if possible the easiest thing to do is to wait for the blood thinners to wash out from the patient's system; hence the daylong wait before this particular patient's cath.
Two more patients were discharged after we visited them - the first was an elderly male with atrial fibrilation. I'm certainly not an expert at reading EKGs, but this was obvious even to me - there were three or four extra waves after the QRS complex, and the T and P waves were buried in the "picket fence" waves. The second discharge was a hemodialysis patient who was meeting with a nephrologist as we were filling out her paperwork. I don't recall exactly what put her on the cardiology service.
After we finished rounding, the cardiologist left and the residents and med student finished up their charting and other tasks. Not feeling the need to stand around and watch them fill out paperwork, I left for lunch. I was supposed to return in the afternoon, but had other work to finish up, so I opted to skip the afternoon rounds. Shhh, don't tell my coordinator. ;)
For those not familiar with academic medicine, perhaps I should explain how rounds work. At least once a day, a particular team of physicians and students will visit their patients, discussing what adjustments need to me made to the patients' medications, etc., and creating a plan for the next 24 hours or so. The ringleader of the circus is the attending physician, and his job is to guide the learning process by asking questions which may or may not directly pertain to the patients the team is treating - it's the Socratic method, basically. The resident doctors and med students attempt to answer the attending's questions while simultaneously writing orders, signing papers, and generally running around like chickens without their heads. If the attending is particularly nasty (or is just in a crappy mood), he will resort to what is known amongst students as "pimping," in which questions are asked in rapid-fire with the sole intent of making the student flustered enough to give a wrong answer. It's not a fun event to witness, and I don't care to think about being on the receiving end of that particular bit of unpleasantness in the future.
Anyway, because the resident was working with cardiology, our team consisted of myself, the resident, another resident, a medical student, and one of the cardiologists. This was a relatively small group; in larger hospitals there can easily be 10 or 15 people on a service. It took nearly three hours to get through all the patients, though only two were new admissions. Since I didn't have the patient list ahead of time, I didn't know much about the patients beyond the two-line blurb on the computer-generated list.
One female patient had pneumonia and bradycardia (slow heart rate). Bradycardia is treated with a pacemaker, but in this case, because she was had no cardiac symptoms, the cardiologist recommended that they skip the pacemaker. Her antibiotics were adjusted and she was told that as long as she could get up and walk around a bit, she would most likely be discharged the next day.
A middle-aged male patient was told that he needed a cardiac catheterization, which would be scheduled for the next day. His Coumadin (blood thinning drug) was halted and he was put on potassium, which reverses the effects of the anticoagulat. Generally, a patient who is about to undergo a surgical procedure is taken off of blood thinners to prevent them from bleeding out. Coagulants can be given if an emergency arises, but those drugs can cause unpleasant side effects, so if possible the easiest thing to do is to wait for the blood thinners to wash out from the patient's system; hence the daylong wait before this particular patient's cath.
Two more patients were discharged after we visited them - the first was an elderly male with atrial fibrilation. I'm certainly not an expert at reading EKGs, but this was obvious even to me - there were three or four extra waves after the QRS complex, and the T and P waves were buried in the "picket fence" waves. The second discharge was a hemodialysis patient who was meeting with a nephrologist as we were filling out her paperwork. I don't recall exactly what put her on the cardiology service.
After we finished rounding, the cardiologist left and the residents and med student finished up their charting and other tasks. Not feeling the need to stand around and watch them fill out paperwork, I left for lunch. I was supposed to return in the afternoon, but had other work to finish up, so I opted to skip the afternoon rounds. Shhh, don't tell my coordinator. ;)
Friday, April 10, 2009
Dietary.
I spent Wednesday morning with the dietitians and diet techs. It wasn't exactly a complete waste of the time, though the woman I was with for most of the morning was a chatterbox and my nerves were wearing a little thin by the time I took off for lunch.
My preceptor gave a short presentation to the kitchen staff about gluten-free diets. For people with Celiac disease, gluten induces an allergic reaction which causes inflammation of the GI tract and makes digestion painful. In the hospital, the food prep people have to be careful about cross-contamination and have special equipment set aside for preparing gluten-free foods.
After the presentation, we rounded through the oncology unit and checked on patients, asking if they had any dietary concerns or needed anything added/subtracted from their meal orders. It's not an easy task to get sick people to eat, and it's harder when the majority have dietary restrictions (mostly diabetic or renal patients) and don't have much choice in their selections anyway. Moreover, the docs are not ordering patient weights as often as in the past, so the dieticians sometimes struggle to know how a patient is faring food-wise.
After oncology I was passed off to another tech, this time to round on one of the med/surg units. While we were standing in the hallway at the nurses station, a pacemaker code was going on a few rooms down. Since I was supposed to be paying attention to the dietician, I wasn't able to really listen to what was going on in that room, but after a few minutes of chaos (docs and nurses running in and out of the room, grabbing supplies, and lots of yelling), the patient was abruptly wheeled out of the room. In the commotion I gathered that they were en route to the cath lab, which meant that the guy probably had a heart attack. The patient definitely looked a little blue as they barreled past us, and just before the team got into the elevator, one of the nurses yelled in a panic, "I can't feel a pulse!" This caused the resident who was running the code to shout a bit too loudly, "No pulse?!? Shit!" But that apparently resolved itself, because they got the patient into the elevator and took off.
A few minutes later, after things had settled down on the floor, the patient's little old wife was brought up in a wheelchair, sobbing and nearing the point of hyperventilation. It took several doctors and nurses to calm her down, though she was still quite (understandably) upset when we left. I sometimes find that watching family members cry is harder than actually watching a patient in distress. For example, while watching the code, all I was really thinking about was whether I wanted a tuna or turkey sandwich for lunch. As soon as the little old lady pulled up, however, I didn't feel quite so hungry anymore. Weird.
My preceptor gave a short presentation to the kitchen staff about gluten-free diets. For people with Celiac disease, gluten induces an allergic reaction which causes inflammation of the GI tract and makes digestion painful. In the hospital, the food prep people have to be careful about cross-contamination and have special equipment set aside for preparing gluten-free foods.
After the presentation, we rounded through the oncology unit and checked on patients, asking if they had any dietary concerns or needed anything added/subtracted from their meal orders. It's not an easy task to get sick people to eat, and it's harder when the majority have dietary restrictions (mostly diabetic or renal patients) and don't have much choice in their selections anyway. Moreover, the docs are not ordering patient weights as often as in the past, so the dieticians sometimes struggle to know how a patient is faring food-wise.
After oncology I was passed off to another tech, this time to round on one of the med/surg units. While we were standing in the hallway at the nurses station, a pacemaker code was going on a few rooms down. Since I was supposed to be paying attention to the dietician, I wasn't able to really listen to what was going on in that room, but after a few minutes of chaos (docs and nurses running in and out of the room, grabbing supplies, and lots of yelling), the patient was abruptly wheeled out of the room. In the commotion I gathered that they were en route to the cath lab, which meant that the guy probably had a heart attack. The patient definitely looked a little blue as they barreled past us, and just before the team got into the elevator, one of the nurses yelled in a panic, "I can't feel a pulse!" This caused the resident who was running the code to shout a bit too loudly, "No pulse?!? Shit!" But that apparently resolved itself, because they got the patient into the elevator and took off.
A few minutes later, after things had settled down on the floor, the patient's little old wife was brought up in a wheelchair, sobbing and nearing the point of hyperventilation. It took several doctors and nurses to calm her down, though she was still quite (understandably) upset when we left. I sometimes find that watching family members cry is harder than actually watching a patient in distress. For example, while watching the code, all I was really thinking about was whether I wanted a tuna or turkey sandwich for lunch. As soon as the little old lady pulled up, however, I didn't feel quite so hungry anymore. Weird.
Tuesday, April 7, 2009
Orthopedics.
I spent yesterday shadowing a PA in the orthopedics department. It was a long clinic day, but I found the cases to be moderately interesting - certainly more so than last week's family practice marathon. Also, I was happy to be back at my home hospital, so I'm sure that helped me get through the drudgery of the 26 patients we saw over the course of the day.
We saw several cases of rotator cuff tendonitis/tears. Most of the patients were being treated with a combination of exercise and steroid injections, and only one of the five or six patients was feeling enough pain to opt for arthroscopic surgery. D., the PA, informed each patient that their recovery would likely take months, but that 90% of patients would heal on on their own, and of the 10% that require surgery, over 94% have good surgical outcomes.
Given the nature of the practice, we also saw a slew of broken bones, mostly in kids (the youngest being a 2-year old girl with a broken tibia following a car accident). Looking at the before and after xrays for each of these patients, I found I could find identify the fractures pretty easily, and even notice old, healed fracture sites. The worst case was a 13-year old male skateboarder who had three fractures in his ankle, including one that split the growth plate into three pie-like slices, or so they appeared on the CT. The kid was, to be blunt, fat and a bit repulsive, and D. told him that he would probably have many more injuries if he continued skateboarding. His mother didn't seem too unhappy with that news. In fact, she was more interested in snapping pictures of the kid's CT scans to share with her friends. The kid was clearly afraid of the fact that he needed surgery to reset the bones, but his mother was obviously clueless and couldn't offer any words of reassurance. Of course, 13-year old boys are universal idiots, and I couldn't exactly blame her for not showing much sympathy. I certainly wasn't going to step up and say anything; I try not to interfere when I sense weird family dynamics.
The most interesting case was a 49-year old male who presented with an acute ruptured Achilles tendon. D. allowed me to feel the patient's good, unbroken left tendon and compare it to the right one. The point of rupture was easily identified because there was an obvious, palpable dent in the tendon (not to mention that the guy's entire lower leg and foot were swollen and bruised). I left for the day after D. told the patient that he would need surgery to sew the tendon back together, and I assume that the procedure was either performed that evening or will be performed sometime within the next 48 hours.
Anyway, for the most part I enjoyed the day, and would like to spend some time in the OR to watch some orthopedic procedures.
We saw several cases of rotator cuff tendonitis/tears. Most of the patients were being treated with a combination of exercise and steroid injections, and only one of the five or six patients was feeling enough pain to opt for arthroscopic surgery. D., the PA, informed each patient that their recovery would likely take months, but that 90% of patients would heal on on their own, and of the 10% that require surgery, over 94% have good surgical outcomes.
Given the nature of the practice, we also saw a slew of broken bones, mostly in kids (the youngest being a 2-year old girl with a broken tibia following a car accident). Looking at the before and after xrays for each of these patients, I found I could find identify the fractures pretty easily, and even notice old, healed fracture sites. The worst case was a 13-year old male skateboarder who had three fractures in his ankle, including one that split the growth plate into three pie-like slices, or so they appeared on the CT. The kid was, to be blunt, fat and a bit repulsive, and D. told him that he would probably have many more injuries if he continued skateboarding. His mother didn't seem too unhappy with that news. In fact, she was more interested in snapping pictures of the kid's CT scans to share with her friends. The kid was clearly afraid of the fact that he needed surgery to reset the bones, but his mother was obviously clueless and couldn't offer any words of reassurance. Of course, 13-year old boys are universal idiots, and I couldn't exactly blame her for not showing much sympathy. I certainly wasn't going to step up and say anything; I try not to interfere when I sense weird family dynamics.
The most interesting case was a 49-year old male who presented with an acute ruptured Achilles tendon. D. allowed me to feel the patient's good, unbroken left tendon and compare it to the right one. The point of rupture was easily identified because there was an obvious, palpable dent in the tendon (not to mention that the guy's entire lower leg and foot were swollen and bruised). I left for the day after D. told the patient that he would need surgery to sew the tendon back together, and I assume that the procedure was either performed that evening or will be performed sometime within the next 48 hours.
Anyway, for the most part I enjoyed the day, and would like to spend some time in the OR to watch some orthopedic procedures.
Wednesday, April 1, 2009
Rural medicine, Day 3.
Today was the most exciting day so far, probably because I spent the morning in the hospital shadowing another of the doctors. The plan as of yesterday afternoon was to follow Dr. M while she rounded on her seven patients, then go back to the clinic in the afternoon. This morning, however, the plan was abruptly shifted when Dr. M ran breathlessly into the hospital and informed me that she had a patient in labor upstairs and that we needed to go, immediately.
To make a long story short, I got to watch the vaginal birth, and it was pretty fun. The mother was doing well and pushed for over an hour, though the baby didn't seem to be moving much and mom was clearly starting to get tired, so Dr. M suggested that they give her a little help with drugs to increase the force of the contractions. The patient reluctantly agreed.
Throughout the first hour I was standing in the corner yawning and trying to keep from falling asleep. After starting the new IV, however, mom-to-be woke me from my stupor with an earsplitting shriek which startled me so badly I almost fell into the sterile table. The howling continued as she pushed and grunted, but fifteen minutes later the baby's head crowned and a less than a minute after that, the baby was out and howling away with a set of lungs to match his mother's. It was quite a rush, watching everything from the foot of the bed. In spite of my great disdain for babies in general, I had to smile as I watched the nurses towel him off. He was a cute baby.
I was more interested in watching what was going on with the baby, to be honest, but I forced myself to pay attention as Dr. M delivered the placenta. That part was bloodier than the actual birth, but I thought it was still pretty cool. The mom had at least stopped screaming after the baby was out, which was good, though she was clearly wiped from the exertion and barely had the strength to look over at the incubator and watch her baby.
We left shortly after Dr. M had filed the appropriate paperwork. All in all, it was a good experience, and I will look forward to watching my next birth. I don't know that the experience was as "miraculous" as some people like to think, but it was certainly a nice break from the endless clinic visits.
To make a long story short, I got to watch the vaginal birth, and it was pretty fun. The mother was doing well and pushed for over an hour, though the baby didn't seem to be moving much and mom was clearly starting to get tired, so Dr. M suggested that they give her a little help with drugs to increase the force of the contractions. The patient reluctantly agreed.
Throughout the first hour I was standing in the corner yawning and trying to keep from falling asleep. After starting the new IV, however, mom-to-be woke me from my stupor with an earsplitting shriek which startled me so badly I almost fell into the sterile table. The howling continued as she pushed and grunted, but fifteen minutes later the baby's head crowned and a less than a minute after that, the baby was out and howling away with a set of lungs to match his mother's. It was quite a rush, watching everything from the foot of the bed. In spite of my great disdain for babies in general, I had to smile as I watched the nurses towel him off. He was a cute baby.
I was more interested in watching what was going on with the baby, to be honest, but I forced myself to pay attention as Dr. M delivered the placenta. That part was bloodier than the actual birth, but I thought it was still pretty cool. The mom had at least stopped screaming after the baby was out, which was good, though she was clearly wiped from the exertion and barely had the strength to look over at the incubator and watch her baby.
We left shortly after Dr. M had filed the appropriate paperwork. All in all, it was a good experience, and I will look forward to watching my next birth. I don't know that the experience was as "miraculous" as some people like to think, but it was certainly a nice break from the endless clinic visits.
Monday, March 30, 2009
Rural Medicine, Day 1.
So, in an unfortunate bout of insanity, my program director has exiled me in a tiny hovel in western PA for the week to shadow the docs at one of my hospital's satellite clinics. Apparently the experience is supposed to make me want to become a family practicioner. So far it is not working.
The doctors and clinic staff are nice enough, though the hospital they take call for is a bit of a joke - 8-bed ER, 6-bed ICU, 3 ORs...it makes me miss my state-of-the-art home hospital. The first two hours of my time here were spent in an excruciatingly long orientation session, in which the coordinator literally went over EVERY SINGLE PAGE of the guide book. I was desperately trying not to claw my eyes out by the end. The only good news is that I get unlimited food at the cafeteria. The downside is that the cafeteria has limited hours and an even more limited selection of food items. Thank Zeus I'm only here until Thursday night.
Anyway, the clinic stuff was pretty boring as well. There were a few "well child" visits, in which the physician assured the nervous parents that their kids were perfectly average, health-wise. There were a few OB-GYN visits, which were so boring I had to pinch myself to keep from falling asleep on my feet. Honestly, how many PAP smears am I going to have to watch this week? I sense many more long hours of staring at funky vaginas. Yuck.
I could go on, but I won't, because I realized midway through the afternoon that any remotely interesting or complicated cases are immediately referred to specialists. It's easy to get the impression that these docs treat a huge variety of illnesses, but the truth is that they really aren't trained to handle people who are a really, really sick. I've pretty much given up hope that I'll see anything more than what I saw today.
I was offhandedly invited to observe a c-section in the hospital tomorrow morning, but since I'm tired and cranky right now, I'm probably going to pass. I need to gather my strength for another long clinic day. Bah humbug.
The doctors and clinic staff are nice enough, though the hospital they take call for is a bit of a joke - 8-bed ER, 6-bed ICU, 3 ORs...it makes me miss my state-of-the-art home hospital. The first two hours of my time here were spent in an excruciatingly long orientation session, in which the coordinator literally went over EVERY SINGLE PAGE of the guide book. I was desperately trying not to claw my eyes out by the end. The only good news is that I get unlimited food at the cafeteria. The downside is that the cafeteria has limited hours and an even more limited selection of food items. Thank Zeus I'm only here until Thursday night.
Anyway, the clinic stuff was pretty boring as well. There were a few "well child" visits, in which the physician assured the nervous parents that their kids were perfectly average, health-wise. There were a few OB-GYN visits, which were so boring I had to pinch myself to keep from falling asleep on my feet. Honestly, how many PAP smears am I going to have to watch this week? I sense many more long hours of staring at funky vaginas. Yuck.
I could go on, but I won't, because I realized midway through the afternoon that any remotely interesting or complicated cases are immediately referred to specialists. It's easy to get the impression that these docs treat a huge variety of illnesses, but the truth is that they really aren't trained to handle people who are a really, really sick. I've pretty much given up hope that I'll see anything more than what I saw today.
I was offhandedly invited to observe a c-section in the hospital tomorrow morning, but since I'm tired and cranky right now, I'm probably going to pass. I need to gather my strength for another long clinic day. Bah humbug.
Thursday, March 26, 2009
Radiation Oncology, OB.
I spent Wednesday morning in radiation oncology. It was pretty much what I expected - essentially, an assembly line of cancer patients herded into the machines, given terrifying amounts of radiation, and herded out. Dr. V was a bit of a creep, but he did give me a thorough explanation of how the oncologists and dosimetry specialists use CT scans and virtual CT scans to direct the radiation beams to precisely target a tumor.
The first patient we saw was a 71-year old man with prostate cancer. He was in the middle of his radiation therapy course, and there were no obvious tumor cells on the CT scan, but Dr. V said that his cancer was probably microscopic at this point, so the radiation was necessary to eradicate as much of the cancer as possible.
The next patient was a sweet old woman who had a mass in her sinuses which had crossed the skull and was infiltrating the area around her pituitary by way of the optic nerves. The woman had initially seen her doctor when she started having double vision, but other than a few moderate sinus headaches a few months ago, she had absolutely no signs or symptoms of her developing tumor. Unfortunately, the tumor's placement made it inoperable, so she was undergoing both chemotherapy and radiation in an attempt to limit the size of the mass and reverse its growth. She seemed in good spirits, all things considered - I can't say that if I had brain cancer I'd be quite as calm.
I spent about an hour with the department's radiation physicist, who is in charge of calibrating the radiation machines and planning brachytherapy procedures. Brachytherapy, for those that don't know, is a radiation technique which involves implanting "seeds" of a radioactive material inside a patient's body for a period of time. The advantage to using these internal radiation sources is that the dosage of radiation can be ramped up significantly, which usually means that the patient gets better faster. Dr. W showed me the ultrasounds of a man with prostate cancer who was being treated with I-125 seeds. The seeds themselves are quite tiny (about 3 mm long), and this particular patient had maybe 30 seeds implanted in his prostate. It was pretty cool, and I was invited to watch the implantation procedure in the OR the next time they have a case.
In the afternoon I made my way up to the labor and delivery unit. Lucky for me, there was absolutely NOTHING going on - no labors, no babies, nada. I wasn't exactly disappointed - I'm sure delivering babies is fun, but after watching ten million "OMG We're having a BAYBEEEE!!!11" shows on TV, I doubt I'd be all that thrilled to just observe a birth. Anyway, after hanging around the ward for an hour, I told the nurses I'd come back another day and left. +1 for me.
The first patient we saw was a 71-year old man with prostate cancer. He was in the middle of his radiation therapy course, and there were no obvious tumor cells on the CT scan, but Dr. V said that his cancer was probably microscopic at this point, so the radiation was necessary to eradicate as much of the cancer as possible.
The next patient was a sweet old woman who had a mass in her sinuses which had crossed the skull and was infiltrating the area around her pituitary by way of the optic nerves. The woman had initially seen her doctor when she started having double vision, but other than a few moderate sinus headaches a few months ago, she had absolutely no signs or symptoms of her developing tumor. Unfortunately, the tumor's placement made it inoperable, so she was undergoing both chemotherapy and radiation in an attempt to limit the size of the mass and reverse its growth. She seemed in good spirits, all things considered - I can't say that if I had brain cancer I'd be quite as calm.
I spent about an hour with the department's radiation physicist, who is in charge of calibrating the radiation machines and planning brachytherapy procedures. Brachytherapy, for those that don't know, is a radiation technique which involves implanting "seeds" of a radioactive material inside a patient's body for a period of time. The advantage to using these internal radiation sources is that the dosage of radiation can be ramped up significantly, which usually means that the patient gets better faster. Dr. W showed me the ultrasounds of a man with prostate cancer who was being treated with I-125 seeds. The seeds themselves are quite tiny (about 3 mm long), and this particular patient had maybe 30 seeds implanted in his prostate. It was pretty cool, and I was invited to watch the implantation procedure in the OR the next time they have a case.
In the afternoon I made my way up to the labor and delivery unit. Lucky for me, there was absolutely NOTHING going on - no labors, no babies, nada. I wasn't exactly disappointed - I'm sure delivering babies is fun, but after watching ten million "OMG We're having a BAYBEEEE!!!11" shows on TV, I doubt I'd be all that thrilled to just observe a birth. Anyway, after hanging around the ward for an hour, I told the nurses I'd come back another day and left. +1 for me.
Monday, March 23, 2009
Pathology, Endocrinology.
I spent the morning shadowing a pathologist. I've been in and out of the clinical labs a few time with other physicians, but haven't spent more than a few minutes at a clip in there. I was first given a tour of the gross cutting room and the slide preparation area, which was interesting. I haven't taken a histology course yet, but I understood most of the procedures they described.
After the first batch of slides were ready, Dr. B and I sat down at one of the multi-headed microscopes and proceeded to look at them. Again, since I don't have much a histology background, I could only differentiate the most obvious structures (fat cells are pretty obvious, for example). Dr. B was pretty good about explaining things, though I was somewhat lost when he pointed out some of the more minute details.
I think it's safe to say that pathology is one of the most cerebral, intellectually-demanding fields in medicine. The amount of knowledge a pathologist must acquire is staggering, and the field definitely attracts a certain personality type - generally those who don't particularly need direct patient contact or a lot of recognition for their work. In exchange for their relative obscurity, pathologists enjoy fairly normal schedules and are compensated quite nicely for their work. With all the new molecular and genetic tests, there is even room for specialization within the field. I'm not convinced that pathology is the field for me, but I can definitely understand why someone would find the field attractive. As much as I love surgery and the excitement of the OR, I am well aware of the kind of lives surgeons lead. Pathology is something to keep in mind for sure.
In a rather abrupt shifting of gears, after lunch I made my way into the clinic to shadow Dr. L, an endocrinologist. As much as I enjoy molecular signaling pathways, I found the actual practice of general endocrinology to be rather bland. Perhaps that is because of the thirteen patients we saw, at least nine were diabetes management cases. I asked Dr. L how many of his cases were diabetes patients, and he said that is was upwards of 90%. So, if you absolutely LOVE diabetes and want to spend your entire career checking glycohemoglobin levels and twiddling with insulin doses, endocrinology is the field for you. Personally, I'm already sick of listening to patients bullshit about why they haven't gotten their blood sugar under control/haven't lost weight/haven't done anything to help themselves, so I think I'll pass.
To be fair, I did see some moderately interesting things. There was a 10-year old girl who had apparently begun showing signs of puberty at age 8, but was otherwise healthy. I saw a few hypothyroid cases, though they were all follow-ups and didn't require too much adjustment of medications. One patient had hypothyroidism and adrenal insufficiency and was on medications for both.
Anyway, it was a rather long afternoon and I was not too disappointed to leave. I doubt I'll be clamoring to shadow endocrinology again anytime soon, but you never know.
After the first batch of slides were ready, Dr. B and I sat down at one of the multi-headed microscopes and proceeded to look at them. Again, since I don't have much a histology background, I could only differentiate the most obvious structures (fat cells are pretty obvious, for example). Dr. B was pretty good about explaining things, though I was somewhat lost when he pointed out some of the more minute details.
I think it's safe to say that pathology is one of the most cerebral, intellectually-demanding fields in medicine. The amount of knowledge a pathologist must acquire is staggering, and the field definitely attracts a certain personality type - generally those who don't particularly need direct patient contact or a lot of recognition for their work. In exchange for their relative obscurity, pathologists enjoy fairly normal schedules and are compensated quite nicely for their work. With all the new molecular and genetic tests, there is even room for specialization within the field. I'm not convinced that pathology is the field for me, but I can definitely understand why someone would find the field attractive. As much as I love surgery and the excitement of the OR, I am well aware of the kind of lives surgeons lead. Pathology is something to keep in mind for sure.
In a rather abrupt shifting of gears, after lunch I made my way into the clinic to shadow Dr. L, an endocrinologist. As much as I enjoy molecular signaling pathways, I found the actual practice of general endocrinology to be rather bland. Perhaps that is because of the thirteen patients we saw, at least nine were diabetes management cases. I asked Dr. L how many of his cases were diabetes patients, and he said that is was upwards of 90%. So, if you absolutely LOVE diabetes and want to spend your entire career checking glycohemoglobin levels and twiddling with insulin doses, endocrinology is the field for you. Personally, I'm already sick of listening to patients bullshit about why they haven't gotten their blood sugar under control/haven't lost weight/haven't done anything to help themselves, so I think I'll pass.
To be fair, I did see some moderately interesting things. There was a 10-year old girl who had apparently begun showing signs of puberty at age 8, but was otherwise healthy. I saw a few hypothyroid cases, though they were all follow-ups and didn't require too much adjustment of medications. One patient had hypothyroidism and adrenal insufficiency and was on medications for both.
Anyway, it was a rather long afternoon and I was not too disappointed to leave. I doubt I'll be clamoring to shadow endocrinology again anytime soon, but you never know.
Thursday, March 19, 2009
Cardiac catheterization lab.
I spent yesterday in the cardiac cath lab and got to see a lot of interesting cases and procedures.
The first procedure of the day was a pacemaker installation. The doctor had difficulty accessing the left subclavian vein due to obstruction and scar tissue from the patient's previous bypass surgery. The patient was pretty adamant that the pacemaker be implanted on the left side, so a cardiothoracic surgeon was called in to access the vein. Once that was done, the wires were implanted in the heart and tested to make sure they could pace the heart properly. Then the actual pacemaker was implanted (I got to unwrap the outer casing and hand it to the nurse). The procedure took 1.5 hours, which was a little ridiculous for so simple an operation.
The second case was a carotid artery stent placement. This was particularly neat because once the doctor had access to the artery, he could inject dye into the line and you could watch the dye spreading up into the patient's brain, the vessels lighting up in real time and the dye becoming more diffuse and it entered smaller and smaller vessels. I thought that was pretty cool.
The third case was a trans-esophogeal echocardiogram, the same technique they use in the OR to make sure repaired/replaced heart valves are working properly. The patient was an obese middle-aged woman who had experienced an episode of blindness/possibly a mini-stroke a few weeks ago. The TEE was supposed to rule out cardiac defects which may have contributed to the episode. To the patient's surprise, the cardiologist found a 10-14 mm hole in the septum which separates the left atrium from the right. This defect is actually fairly common; it affects about 1 person out of 5, though most people are asymptomatic and never know they have it. In this patient's case, the hole was large enough that blood was flowing from the left atrium to the right, which never happens in a normal heart. This extra blood in the right side of the heart caused the right atrium and ventricle walls to enlarge slightly. The cardiologist recommended that because of its side, the patient should have the hole closed up, and that doing so might solve her mini-stroke problem.
The next case was an actual cardiac catheterization; the doctor was looking for possible mitral valve stenosis and measuring the pressures inside the heart chambers. Everything was going smoothly until the doctor advanced the wire down through the aorta and into the left atrium. At that point, the patient's heart rate and blood pressure dropped so abruptly that the next thing I knew, the doctor was shouting, "Atropine! ATROPINE!!!" and the nurses were scrambling to inject the drugs and increase the woman's fluid intake. After waiting about fifteen minutes for the patient to stabilize and stop feeling so nauseous from the sudden drug dose, the procedure continued without interruption. It was quite exciting, and totally woke me up from my after-lunch stupor.
The final case was an emergency coronary artery catheterization and stent placement. This case lasted over an hour and there were several intense moments when it appeared the patient was going to have to undergo emergency bypass surgery, because the doctor couldn't advance the wires far enough into the artery; the vessels were too blocked. The doctor was forced to used a diamond-tipped drill to blast away some of the calcification inside the artery so he could fit his stent and balloon in there. That was pretty intense; we were all holding our collective breath when the drill roared to life and everyone's eyes were glued the the EKG monitor, waiting to see how the patient would respond. Ultimately the procedure was successful and two stents were placed, but the doctor turned to me just before he left and said, "That was a close one."
Anyway, it was a very interesting and informative day, though after wearing a heavy lead apron for nearly 9 hours my shoulders and back were aching and I pretty much collapsed when I got back to my room. The nurses told me to come back anytime, and I may take them up on the offer, since aside from the discomfort of the apron, I had a really enjoyable time.
The first procedure of the day was a pacemaker installation. The doctor had difficulty accessing the left subclavian vein due to obstruction and scar tissue from the patient's previous bypass surgery. The patient was pretty adamant that the pacemaker be implanted on the left side, so a cardiothoracic surgeon was called in to access the vein. Once that was done, the wires were implanted in the heart and tested to make sure they could pace the heart properly. Then the actual pacemaker was implanted (I got to unwrap the outer casing and hand it to the nurse). The procedure took 1.5 hours, which was a little ridiculous for so simple an operation.
The second case was a carotid artery stent placement. This was particularly neat because once the doctor had access to the artery, he could inject dye into the line and you could watch the dye spreading up into the patient's brain, the vessels lighting up in real time and the dye becoming more diffuse and it entered smaller and smaller vessels. I thought that was pretty cool.
The third case was a trans-esophogeal echocardiogram, the same technique they use in the OR to make sure repaired/replaced heart valves are working properly. The patient was an obese middle-aged woman who had experienced an episode of blindness/possibly a mini-stroke a few weeks ago. The TEE was supposed to rule out cardiac defects which may have contributed to the episode. To the patient's surprise, the cardiologist found a 10-14 mm hole in the septum which separates the left atrium from the right. This defect is actually fairly common; it affects about 1 person out of 5, though most people are asymptomatic and never know they have it. In this patient's case, the hole was large enough that blood was flowing from the left atrium to the right, which never happens in a normal heart. This extra blood in the right side of the heart caused the right atrium and ventricle walls to enlarge slightly. The cardiologist recommended that because of its side, the patient should have the hole closed up, and that doing so might solve her mini-stroke problem.
The next case was an actual cardiac catheterization; the doctor was looking for possible mitral valve stenosis and measuring the pressures inside the heart chambers. Everything was going smoothly until the doctor advanced the wire down through the aorta and into the left atrium. At that point, the patient's heart rate and blood pressure dropped so abruptly that the next thing I knew, the doctor was shouting, "Atropine! ATROPINE!!!" and the nurses were scrambling to inject the drugs and increase the woman's fluid intake. After waiting about fifteen minutes for the patient to stabilize and stop feeling so nauseous from the sudden drug dose, the procedure continued without interruption. It was quite exciting, and totally woke me up from my after-lunch stupor.
The final case was an emergency coronary artery catheterization and stent placement. This case lasted over an hour and there were several intense moments when it appeared the patient was going to have to undergo emergency bypass surgery, because the doctor couldn't advance the wires far enough into the artery; the vessels were too blocked. The doctor was forced to used a diamond-tipped drill to blast away some of the calcification inside the artery so he could fit his stent and balloon in there. That was pretty intense; we were all holding our collective breath when the drill roared to life and everyone's eyes were glued the the EKG monitor, waiting to see how the patient would respond. Ultimately the procedure was successful and two stents were placed, but the doctor turned to me just before he left and said, "That was a close one."
Anyway, it was a very interesting and informative day, though after wearing a heavy lead apron for nearly 9 hours my shoulders and back were aching and I pretty much collapsed when I got back to my room. The nurses told me to come back anytime, and I may take them up on the offer, since aside from the discomfort of the apron, I had a really enjoyable time.
Tuesday, March 17, 2009
Vascular surgery.
I spent Monday working in Dr. S's vascular clinic. It was an insane day - from 8 AM to 5 PM we were seeing patients basically nonstop - I had a fifteen minute break for lunch midafternoon, but other than that we were running around pretty much constantly.
Even though I dislike clinic, I admit that I learned quite a bit. I'm finding that I'm getting much better at locating things on CT scans and ultrasounds. I'm pretty sure I could now point out a decent-sized abdominal aortic aneurysm (AAA) on a CT, for example.
Anyway, the day was spent doing patient evaluations and follow-ups. The first patient was a 71-year old woman with pain in an old AV hemodialysis fistula. I'd already encountered AV fistulas when I shadowed nephrology and dialysis, but it was neat to be able to feel another one.
At some point I was instructed to head off with one of the ultrasound techs and watch them perform a carotid ultrasound on a middle-aged man. That was pretty neat because you could clearly see the areas of stenosis by watching the blood flow.
In a weird twist of luck, I got to see the same woman with the huge leg ulcer I described a few weeks ago - this time being evaluated following her unilateral above-knee amputation. According to Dr. S, the wound site was healing nicely, though there was a bit of raised swelling around the staples, leading him to think that she might have developed a fungal infection.
The neatest case of the day was a 70-ish man visiting post-AAA repair. Endovascular aneurysm repair involves fitting a synthetic graft inside the damaged blood vessel so a thrombus forms in the space between the graft and vessel wall, with the blood rerouted inside the graft. This takes the pressure off the native vessel and prevents it from rupturing. Anyway, Dr. S showed me the patient's post-op CT scan, where the graft and the wires were clearly visible running down the aorta and branching into the iliac arteries. I thought that was pretty cool.
All in all, it was a very educational day, though I'm not eager to repeat that sort of crazy clinic schedule anytime soon. I meant to go for a run yesterday because the weather was so lovely, but by the time I got back to my room and kicked off my shoes, it was all I could do not to collapse for the night. Blah.
Even though I dislike clinic, I admit that I learned quite a bit. I'm finding that I'm getting much better at locating things on CT scans and ultrasounds. I'm pretty sure I could now point out a decent-sized abdominal aortic aneurysm (AAA) on a CT, for example.
Anyway, the day was spent doing patient evaluations and follow-ups. The first patient was a 71-year old woman with pain in an old AV hemodialysis fistula. I'd already encountered AV fistulas when I shadowed nephrology and dialysis, but it was neat to be able to feel another one.
At some point I was instructed to head off with one of the ultrasound techs and watch them perform a carotid ultrasound on a middle-aged man. That was pretty neat because you could clearly see the areas of stenosis by watching the blood flow.
In a weird twist of luck, I got to see the same woman with the huge leg ulcer I described a few weeks ago - this time being evaluated following her unilateral above-knee amputation. According to Dr. S, the wound site was healing nicely, though there was a bit of raised swelling around the staples, leading him to think that she might have developed a fungal infection.
The neatest case of the day was a 70-ish man visiting post-AAA repair. Endovascular aneurysm repair involves fitting a synthetic graft inside the damaged blood vessel so a thrombus forms in the space between the graft and vessel wall, with the blood rerouted inside the graft. This takes the pressure off the native vessel and prevents it from rupturing. Anyway, Dr. S showed me the patient's post-op CT scan, where the graft and the wires were clearly visible running down the aorta and branching into the iliac arteries. I thought that was pretty cool.
All in all, it was a very educational day, though I'm not eager to repeat that sort of crazy clinic schedule anytime soon. I meant to go for a run yesterday because the weather was so lovely, but by the time I got back to my room and kicked off my shoes, it was all I could do not to collapse for the night. Blah.
Sunday, March 15, 2009
Cardiac surgery.
On Friday I finally had the opportunity to watch open heart surgery. It was absolutely amazing.
This particular surgery was an aortic valve replacement, or AVR - it was actually a redo of the same surgery the patient had undergone about ten years ago. It's a fairly common procedure; according to the perfusion tech who was running the bypass machine, if they do 10 heart surgeries every week, 4 or 5 will be valve repairs or replacements.
The patient was brought into the OR at 8:00 AM. The nurses had already been prepping the room for over half an hour prior to the patient's arrival. Things moved quickly once the surgeon (a FEMALE! Woo!) arrived; the nurses and the surgeon scrubbed in, and the patient was draped while the anesthesiologist put the patient fully to sleep and checked all the lines and equipment, and then the surgery began.
Dr. R (the surgeon) made a long incision down the patient's chest using a scalpel and bovie. The breastbone was soon exposed and Dr. R removed the six metal wires holding the bone together from the patient's previous AVR. There was quite a lot of scar tissue, so before the breastbone could be sawed through, Dr. R used her hands to reach under the bone from the top and bottom to make sure that the heart and pericardium hadn't become attached to the bone. She then used a jigsaw to slice through the breastbone, fitted a retractor on either side, and opened the thoracic cavity.
I only caught a glance at the opening for a few seconds, but from where I was standing near the patient's head, the heart could clearly be seen pulsating under the pericardium, and the lower lobes of the lungs could be seen expanding and contracting through the scar tissue on either side of the heart. It was pretty cool.
The next two hours were spent putting the patient on the cardiopulmonary bypass machine. I won't go into the details of how that was done, but if you're interested, here is the Wikipedia article describing the process.
With the patient on bypass and the heart and lungs stopped, Dr. R moved on to the actual procedure. With the help of another surgeon, she removed the old aortic valve and fitted the patient for a new one using a special set of measuring devices. She then used 16 sets of sutures to sew the replacement valve into the aorta and sewed the aorta closed. At this point the patient was taken off of bypass and the perfusion tech began to rewarm the body by warming the returning oxygenated blood. After checking the valve placement with a transesophogeal echocardiogram (TEE), the clamp on the aorta was removed. Ten minutes later the bypass pump was turned off and the patient's heart and lungs began working on their own again.
The rest of the surgery involved removing the cannulas from the heart, checking the new valve again with the TEE, and closing the surgical site with a combination of metal wires, subcutaneous sutures, and superficial sutures. The entire surgery lasted about 4.5 hours; the patient was on bypass for 2 hours and of that time, the aorta was clamped for 98 minutes. I learned that this was important because the longer the aorta is clamped, the higher the risk for spinal cord ischemia and paralysis.
After the surgical site was closed and all the instruments accounted for (107 needles alone needed to be counted!), the patient was transported to the surgical ICU, where he would recover and be monitored for a few days. I left the OR in a strange state of excited calmness, mind racing but feeling oddly relaxed and peaceful regarding what I had just witnessed. Thinking about it now, I was probably just tired from standing in one position for so long.
All in all, it was a fantastic experience, and I consider myself very lucky to have been able to watch such an intense procedure up close.
This particular surgery was an aortic valve replacement, or AVR - it was actually a redo of the same surgery the patient had undergone about ten years ago. It's a fairly common procedure; according to the perfusion tech who was running the bypass machine, if they do 10 heart surgeries every week, 4 or 5 will be valve repairs or replacements.
The patient was brought into the OR at 8:00 AM. The nurses had already been prepping the room for over half an hour prior to the patient's arrival. Things moved quickly once the surgeon (a FEMALE! Woo!) arrived; the nurses and the surgeon scrubbed in, and the patient was draped while the anesthesiologist put the patient fully to sleep and checked all the lines and equipment, and then the surgery began.
Dr. R (the surgeon) made a long incision down the patient's chest using a scalpel and bovie. The breastbone was soon exposed and Dr. R removed the six metal wires holding the bone together from the patient's previous AVR. There was quite a lot of scar tissue, so before the breastbone could be sawed through, Dr. R used her hands to reach under the bone from the top and bottom to make sure that the heart and pericardium hadn't become attached to the bone. She then used a jigsaw to slice through the breastbone, fitted a retractor on either side, and opened the thoracic cavity.
I only caught a glance at the opening for a few seconds, but from where I was standing near the patient's head, the heart could clearly be seen pulsating under the pericardium, and the lower lobes of the lungs could be seen expanding and contracting through the scar tissue on either side of the heart. It was pretty cool.
The next two hours were spent putting the patient on the cardiopulmonary bypass machine. I won't go into the details of how that was done, but if you're interested, here is the Wikipedia article describing the process.
With the patient on bypass and the heart and lungs stopped, Dr. R moved on to the actual procedure. With the help of another surgeon, she removed the old aortic valve and fitted the patient for a new one using a special set of measuring devices. She then used 16 sets of sutures to sew the replacement valve into the aorta and sewed the aorta closed. At this point the patient was taken off of bypass and the perfusion tech began to rewarm the body by warming the returning oxygenated blood. After checking the valve placement with a transesophogeal echocardiogram (TEE), the clamp on the aorta was removed. Ten minutes later the bypass pump was turned off and the patient's heart and lungs began working on their own again.
The rest of the surgery involved removing the cannulas from the heart, checking the new valve again with the TEE, and closing the surgical site with a combination of metal wires, subcutaneous sutures, and superficial sutures. The entire surgery lasted about 4.5 hours; the patient was on bypass for 2 hours and of that time, the aorta was clamped for 98 minutes. I learned that this was important because the longer the aorta is clamped, the higher the risk for spinal cord ischemia and paralysis.
After the surgical site was closed and all the instruments accounted for (107 needles alone needed to be counted!), the patient was transported to the surgical ICU, where he would recover and be monitored for a few days. I left the OR in a strange state of excited calmness, mind racing but feeling oddly relaxed and peaceful regarding what I had just witnessed. Thinking about it now, I was probably just tired from standing in one position for so long.
All in all, it was a fantastic experience, and I consider myself very lucky to have been able to watch such an intense procedure up close.
Wednesday, March 11, 2009
Family practice.
I spent the morning shadowing a family physician in the clinic. I could have stayed the entire day, but I was fed up with the nonsense and decided I'd be better served working on my own than listening to inane patient complaints.
The day started with a 40-ish female complaining that last week, she experienced a sudden onset of hives and swelling in her hands and feet. The rash went away and the swelling went down, leading Dr. B and I to conclude that is was probably an allergic reaction.
The next patient was a woman who wanted to discuss weight loss surgery. She hadn't been able to lose weight with a reported good diet and exercise (which is a load of baloney), but wanted the consult anyway. Dr. B told her that in order to even be a candidate for the surgery, she needed to prove that she was losing some weight the old fashioned way. I did not get the impression that the patient was particularly compliant, but you never know.
The saddest patient was a woman who came in complaining of extreme nausea and stomach pain. When Dr. B asked what was wrong, the woman burst into tears and spilled a terrible story about her 22-year old stepson, who was diagnosed with terminal brain cancer and who was put on hospice care this week. Apparently the kid is not expected to live to see the end of the month. Clearly the woman's symptoms were related to her anxiety and stress, so Dr. B gave her some meds and told her to come back in a week.
The next patient was a middle-aged woman who had seen blood in her urine this morning. Dr. B asked for a urine sample but the patient couldn't give one, so Dr. B performed a pelvic exam. The woman had some blood around the outside of her vagina but not inside. Dr. B said it was probably a UTI and gave her a weeklong course of antibiotics to see if that would clear it up.
The next patient was a young lady who needed a physical and gynecological exam. Nothing particularly exciting there; I was pretty much yawning in the corner by that point.
Anyway, to make a long story short, it went on like that, most of the cases extremely boring and pointless, etc. I have no desire to be a primary care doctor, but I knew that already. Woo.
The day started with a 40-ish female complaining that last week, she experienced a sudden onset of hives and swelling in her hands and feet. The rash went away and the swelling went down, leading Dr. B and I to conclude that is was probably an allergic reaction.
The next patient was a woman who wanted to discuss weight loss surgery. She hadn't been able to lose weight with a reported good diet and exercise (which is a load of baloney), but wanted the consult anyway. Dr. B told her that in order to even be a candidate for the surgery, she needed to prove that she was losing some weight the old fashioned way. I did not get the impression that the patient was particularly compliant, but you never know.
The saddest patient was a woman who came in complaining of extreme nausea and stomach pain. When Dr. B asked what was wrong, the woman burst into tears and spilled a terrible story about her 22-year old stepson, who was diagnosed with terminal brain cancer and who was put on hospice care this week. Apparently the kid is not expected to live to see the end of the month. Clearly the woman's symptoms were related to her anxiety and stress, so Dr. B gave her some meds and told her to come back in a week.
The next patient was a middle-aged woman who had seen blood in her urine this morning. Dr. B asked for a urine sample but the patient couldn't give one, so Dr. B performed a pelvic exam. The woman had some blood around the outside of her vagina but not inside. Dr. B said it was probably a UTI and gave her a weeklong course of antibiotics to see if that would clear it up.
The next patient was a young lady who needed a physical and gynecological exam. Nothing particularly exciting there; I was pretty much yawning in the corner by that point.
Anyway, to make a long story short, it went on like that, most of the cases extremely boring and pointless, etc. I have no desire to be a primary care doctor, but I knew that already. Woo.
Monday, March 9, 2009
Helicopter!
I spent the day with the hospital's contracted medevac helicopter crew. The flight nurse in charge of the ride-along program gave me a tour of the helicopter and fitted me for a jumpsuit (VERY stylish), helmet, and seatbelt. The inside of the helicopter looks a lot like the inside of an ambulance, except that there are two seats in the back instead of one, and the doors and windows have slightly more complicated latches (obviously). Most of the equipment is the same, but packed into a smaller space.
The morning passed without any calls. The crew was nice and let me set up camp in their living area, so I spent the time catching up on reading and watching TV. Just as I was finishing up my lunch around 12:30, a call came in. We headed out.
Having never been in a helicopter before, I was a bit nervous about the actual flying bit, but it was actually quite a lot of fun. It was rather windy today, though, so the copter was rocking around a lot and dipped a few times, which made the bottom of my stomach drop. The view was absolutely lovely, even for a yucky, rainy March day. I was probably grinning like an idiot for most of the ride.
We flew for about 15 minutes before landing on a school baseball field, where an ambulance crew and firefighters were waiting. The patient was a 67-year old woman in respiratory distress, extremely hypotensive (BP something like 60/45) and unresponsive, but otherwise showing no signs of trauma. The flight nurse and paramedic went into the ambulance and did their assessment, stabilized the patient (I didn't get to watch this), then the firefighters and medics moved the patient from the ambulance stretcher to the helicopter stretcher, into the helicopter, and we took off. I got to sit in the front seat this time, which was even more fun, because the view wasn't obstructed by equipment. Unfortunately, this also meant that I couldn't watch what was happening with the patient, but I could hear what the medics were saying through my headset. At one point the pilot and I had to laugh because the medics were swearing up a storm. Even though the patient was sedated and probably couldn't hear them over the whir of the blades anyway, it was unexpected. Apparently the paramedic had accidentally connected two syringe pumps to each other instead of the to the patient, causing blood in one of the lines to spurt all over the place. He gave me a guilty look when I glanced into the back of the copter, which I also found amusing.
It took another 15 minutes to fly back to the hospital. We landed on the Helipad and wheeled the patient into the ER, where they were waiting for us in a trauma room. We left shortly thereafter, so I really don't know what happened or what the final diagnosis was; I heard the doctor mention something about a CT to rule out stroke, and xray was just coming in to check the placement of the breathing tube while we were leaving.
We flew back to base and I spent the rest of the afternoon working and watching more TV. No other calls came in, so I left around 5. Since the crew averages 1.5 flights a day, I figured it would probably be nighttime when the next call came in. I wasn't disappointed to leave; I was lucky that I got to fly at all.
So, if you ever get the opportunity to fly in a helicopter, I say go for it. It's a thrill ride for sure, but a unique experience, and a fun one, and a great way to see the scenery. I will certainly jump on the chance to ride in one again in the future. :)
The morning passed without any calls. The crew was nice and let me set up camp in their living area, so I spent the time catching up on reading and watching TV. Just as I was finishing up my lunch around 12:30, a call came in. We headed out.
Having never been in a helicopter before, I was a bit nervous about the actual flying bit, but it was actually quite a lot of fun. It was rather windy today, though, so the copter was rocking around a lot and dipped a few times, which made the bottom of my stomach drop. The view was absolutely lovely, even for a yucky, rainy March day. I was probably grinning like an idiot for most of the ride.
We flew for about 15 minutes before landing on a school baseball field, where an ambulance crew and firefighters were waiting. The patient was a 67-year old woman in respiratory distress, extremely hypotensive (BP something like 60/45) and unresponsive, but otherwise showing no signs of trauma. The flight nurse and paramedic went into the ambulance and did their assessment, stabilized the patient (I didn't get to watch this), then the firefighters and medics moved the patient from the ambulance stretcher to the helicopter stretcher, into the helicopter, and we took off. I got to sit in the front seat this time, which was even more fun, because the view wasn't obstructed by equipment. Unfortunately, this also meant that I couldn't watch what was happening with the patient, but I could hear what the medics were saying through my headset. At one point the pilot and I had to laugh because the medics were swearing up a storm. Even though the patient was sedated and probably couldn't hear them over the whir of the blades anyway, it was unexpected. Apparently the paramedic had accidentally connected two syringe pumps to each other instead of the to the patient, causing blood in one of the lines to spurt all over the place. He gave me a guilty look when I glanced into the back of the copter, which I also found amusing.
It took another 15 minutes to fly back to the hospital. We landed on the Helipad and wheeled the patient into the ER, where they were waiting for us in a trauma room. We left shortly thereafter, so I really don't know what happened or what the final diagnosis was; I heard the doctor mention something about a CT to rule out stroke, and xray was just coming in to check the placement of the breathing tube while we were leaving.
We flew back to base and I spent the rest of the afternoon working and watching more TV. No other calls came in, so I left around 5. Since the crew averages 1.5 flights a day, I figured it would probably be nighttime when the next call came in. I wasn't disappointed to leave; I was lucky that I got to fly at all.
So, if you ever get the opportunity to fly in a helicopter, I say go for it. It's a thrill ride for sure, but a unique experience, and a fun one, and a great way to see the scenery. I will certainly jump on the chance to ride in one again in the future. :)
Sunday, March 1, 2009
Reflection.
It's approximately the halfway point of the semester, so I thought I'd write something a bit different and perhaps more reflective than the usual "This is what I saw" entry.
Even though I've only been in the hospital for two months, I definitely feel that my perspective has changed about a lot of things related to medicine and medical education. I realize I am incredibly lucky to be able to see the inner workings of medicine this early in my career, but at the same time I'm realizing that I'm also being soured in some ways by what I have seen.
Take, for example, the barbaric ritual known as "night float," in which a SINGLE intern is responsible for keeping 50+ patients alive through the night. It is always easy to spot the unlucky individual the next morning, because he or she looks absolutely dead from running all around the hospital all night long. I haven't yet entered med school and already I am dreading night float.
The crappy treatment med students and residents must endure is probably the biggest turn-off for me. There is a huge discontinuity between what is taught during the first two years of med school and the scut work the 3rd- and 4th-year students and residents must perform as part of their training. You don't need a medical degree to wipe up vomit or run to get your attending a cup of coffee. It's discouraging to know that even after putting in this much time and energy into my education, it will still be many, many years before I'm no longer at the bottom of the totem pole.
Though the vast majority of the doctors and nurses have been friendly and encouraging, I've encountered enough big egos and less-than-sensitive types to have lost some of my initial naivete. After mentioning that I liked being in the OR, I've been told that women should not become surgeons. I've been warned not to form any long-term relationships because I will not be able to maintain them through the clinical years. I've been told once or twice to reconsider the entire field and get out before I'm too deeply immersed in student loans to turn back. None of these remarks have had their desired effect; I still think I can be happy and successful in medicine, but they certainly put a bit of a damper on my enthusiasm.
As I said, it's a mixed blessing to be in the hospital before starting med school. Yes, I have a much clearer picture of what I will be facing in a few years and yes, I am comfortable with moving around the hospital and walking into patients' rooms and all of that, but the enormity of my decision to become a physician is brought to the forefront of my mind every time I watch a procedure or hear a code announced on the loudspeaker. The pressure to perform well has already begun, and it will only get much, much worse come August. I'm trying not to psych myself out and for the most part I think I'm doing okay, but my few moments of self-doubt have been paralyzing in a way I've never experienced before.
I could go on, but I'll save the rest for future posts. Homework calls.
Even though I've only been in the hospital for two months, I definitely feel that my perspective has changed about a lot of things related to medicine and medical education. I realize I am incredibly lucky to be able to see the inner workings of medicine this early in my career, but at the same time I'm realizing that I'm also being soured in some ways by what I have seen.
Take, for example, the barbaric ritual known as "night float," in which a SINGLE intern is responsible for keeping 50+ patients alive through the night. It is always easy to spot the unlucky individual the next morning, because he or she looks absolutely dead from running all around the hospital all night long. I haven't yet entered med school and already I am dreading night float.
The crappy treatment med students and residents must endure is probably the biggest turn-off for me. There is a huge discontinuity between what is taught during the first two years of med school and the scut work the 3rd- and 4th-year students and residents must perform as part of their training. You don't need a medical degree to wipe up vomit or run to get your attending a cup of coffee. It's discouraging to know that even after putting in this much time and energy into my education, it will still be many, many years before I'm no longer at the bottom of the totem pole.
Though the vast majority of the doctors and nurses have been friendly and encouraging, I've encountered enough big egos and less-than-sensitive types to have lost some of my initial naivete. After mentioning that I liked being in the OR, I've been told that women should not become surgeons. I've been warned not to form any long-term relationships because I will not be able to maintain them through the clinical years. I've been told once or twice to reconsider the entire field and get out before I'm too deeply immersed in student loans to turn back. None of these remarks have had their desired effect; I still think I can be happy and successful in medicine, but they certainly put a bit of a damper on my enthusiasm.
As I said, it's a mixed blessing to be in the hospital before starting med school. Yes, I have a much clearer picture of what I will be facing in a few years and yes, I am comfortable with moving around the hospital and walking into patients' rooms and all of that, but the enormity of my decision to become a physician is brought to the forefront of my mind every time I watch a procedure or hear a code announced on the loudspeaker. The pressure to perform well has already begun, and it will only get much, much worse come August. I'm trying not to psych myself out and for the most part I think I'm doing okay, but my few moments of self-doubt have been paralyzing in a way I've never experienced before.
I could go on, but I'll save the rest for future posts. Homework calls.
Wednesday, February 25, 2009
ER.
Today I shadowed the attending ER physician, Dr. B. The morning was quite slow; we only saw two or three patients, none of which were particularly interesting - colds, flu, etc. Consequently, I spent most of the time catching up on my reading in the break room.
The afternoon began slowly but things picked up by 2 pm. By 3 pm it was getting a little nuts; the ambulance crews just kept coming in with new patients, and triaged patients were starting to stack up on the extra beds in the hallway.
At about 3:30, an elderly woman with severe lung disease was brought in by ambulance. Dr. B and the other physician went into the room to take a look, and when Dr. B came out, he simply pointed at me and said, "Go." I went.
It was exactly, EXACTLY like a TV show: ten, maybe 12 people all crowded around the bed, running around, shouting orders. The patient was extremely obese and completely naked on the table, clearly unconscious. The nurses were trying to get an IV started but they had difficulty finding the appropriate blood vessel. The woman's airway was partially obstructed so the docs were simultaneously having difficulty getting the breathing tube in. To keep her breathing, they injected some drugs, but I didn't catch all the drug names. They finally intubated her and her pulse ox stats immediately went from the low 60s to the high 80s, and her heart rate jumped from about 35 bpm to about 90. The patient was still in critical condition but she was stable, so they brought in the x-ray people to make sure the breathing tube was properly placed.
Respiratory therapy was called to connect the patient to the ventilator. Before hooking her up, the respiratory therapist suctioned up a quantity of what they told me was probably a large pulmonary edema. Finally, the ER doc drew about 25 cc of blood from the femoral artery (with two nurses retracting the patient's enormous abdomen), and the resident started an arterial line in the patient's arm, which spurted blood all over the table before he got it in properly. The room cleared a bit as some of the nurses left, but not before Dr. B peeked in and said to me, "Now that's some serious medicine!" I had to agree. It was pretty intense.
There are two major morals to this story:
1) Don't smoke.
2) Don't be fat.
The last I heard, the resident was trying to get the patient admitted, but the pulmonary service didn't want her, so he was trying to convince cardiology to her on. I'm not sure what happened.
So...I survived my first real trauma. It was terribly exciting, but after that patient I was tired and left for the day. I was pretty much just in the way the entire time anyway, so I figured the staff wouldn't notice my absence.
The afternoon began slowly but things picked up by 2 pm. By 3 pm it was getting a little nuts; the ambulance crews just kept coming in with new patients, and triaged patients were starting to stack up on the extra beds in the hallway.
At about 3:30, an elderly woman with severe lung disease was brought in by ambulance. Dr. B and the other physician went into the room to take a look, and when Dr. B came out, he simply pointed at me and said, "Go." I went.
It was exactly, EXACTLY like a TV show: ten, maybe 12 people all crowded around the bed, running around, shouting orders. The patient was extremely obese and completely naked on the table, clearly unconscious. The nurses were trying to get an IV started but they had difficulty finding the appropriate blood vessel. The woman's airway was partially obstructed so the docs were simultaneously having difficulty getting the breathing tube in. To keep her breathing, they injected some drugs, but I didn't catch all the drug names. They finally intubated her and her pulse ox stats immediately went from the low 60s to the high 80s, and her heart rate jumped from about 35 bpm to about 90. The patient was still in critical condition but she was stable, so they brought in the x-ray people to make sure the breathing tube was properly placed.
Respiratory therapy was called to connect the patient to the ventilator. Before hooking her up, the respiratory therapist suctioned up a quantity of what they told me was probably a large pulmonary edema. Finally, the ER doc drew about 25 cc of blood from the femoral artery (with two nurses retracting the patient's enormous abdomen), and the resident started an arterial line in the patient's arm, which spurted blood all over the table before he got it in properly. The room cleared a bit as some of the nurses left, but not before Dr. B peeked in and said to me, "Now that's some serious medicine!" I had to agree. It was pretty intense.
There are two major morals to this story:
1) Don't smoke.
2) Don't be fat.
The last I heard, the resident was trying to get the patient admitted, but the pulmonary service didn't want her, so he was trying to convince cardiology to her on. I'm not sure what happened.
So...I survived my first real trauma. It was terribly exciting, but after that patient I was tired and left for the day. I was pretty much just in the way the entire time anyway, so I figured the staff wouldn't notice my absence.
Monday, February 23, 2009
Vascular surgery.
I spent the day with a first-year surgery resident. The general surgery residency here is divided into four services: general A and B, vascular, and trauma. Originally I was supposed to be with one of the general surgery teams, but a number of people were out sick or on vacation, so I was put on vascular.
I spent most of the morning in the OR, watching two procedures. They were both Portacath implantations, which are not the most exciting to watch because the devices are implanted just under the skin and there isn't a whole lot to observe. The surgeons used x-ray to position the catheter in the appropriate vein, then cut a small pocket to fit the septum and closed the incision with one or two small stitches. The patients weren't even intubated; since the entire procedure took maybe 30 minutes and was minimally invasive (in terms of the size of the incisions and the risks of the procedure), the patients were only sedated. That certainly sped up the process; sometimes putting a patient to sleep can take a while if their airway is difficult to access, the tube isn't sitting properly in the airway, etc.
I elected not to watch the following two vascular procedures, one of which was another Portacath insertion. Instead, I followed the resident to the clinic and even though the rest of the day was incredibly boring, the first patient we saw was worth skipping the OR.
The patient was a 60-some year old woman who had been paralyzed two years ago when she contracted an infection following chemotherapy and radiation treatment for lesions on her lymph nodes. The poor woman contracted pretty much every horrible infection there is to contract - MRSA, VRE - you name it, she had it. She is allergic to penicillin but ultimately, penicillin is exactly what stopped the infections.
Following a 7-week stay in the ICU while she was battling the infections, the woman endured months of rehab because she could no longer walk. She developed sores on her coccyx and legs which blossomed into full-blown skin ulcers. She was given standard wound care treatment, but it didn't help.
The wound on her coccyx has since healed nicely without any treatment other than frequent dressing changes. The wound on her leg was manageable up until a few weeks ago, when it suddenly ballooned to about 4 inches long. The woman didn't have any fever, though, so the docs didn't think the wound was infected. That was all well and good, except that in the past week and a half, the ulcer has grown to over 7 inches long.
I was not exactly prepared when the resident removed this patient's wound dressings. If you can imagine what a human leg would look like if a dinosaur took a huge bite out of the calf, that's pretty much exactly what the ulcer looked like. It was ENORMOUS and wet and drippy and purulent and the tendons were poking out horribly, though no bone was (yet) showing. Lucky the woman was paralyzed and couldn't feel it - I can't imagine how painful a wound like that would be on someone with good sensation in the legs.
At any rate, the vascular surgeon looked at the ulcer for about five seconds and told the woman that she needed an amputation, pronto. They scheduled the surgery for next week.
Though I'm probably going to have the image of that festering, dripping ulcer in my head for quite some time, I guess experiencing these disgusting things now will only help later when I'll be the one who has to actually touch the patient. Yuck.
I spent most of the morning in the OR, watching two procedures. They were both Portacath implantations, which are not the most exciting to watch because the devices are implanted just under the skin and there isn't a whole lot to observe. The surgeons used x-ray to position the catheter in the appropriate vein, then cut a small pocket to fit the septum and closed the incision with one or two small stitches. The patients weren't even intubated; since the entire procedure took maybe 30 minutes and was minimally invasive (in terms of the size of the incisions and the risks of the procedure), the patients were only sedated. That certainly sped up the process; sometimes putting a patient to sleep can take a while if their airway is difficult to access, the tube isn't sitting properly in the airway, etc.
I elected not to watch the following two vascular procedures, one of which was another Portacath insertion. Instead, I followed the resident to the clinic and even though the rest of the day was incredibly boring, the first patient we saw was worth skipping the OR.
The patient was a 60-some year old woman who had been paralyzed two years ago when she contracted an infection following chemotherapy and radiation treatment for lesions on her lymph nodes. The poor woman contracted pretty much every horrible infection there is to contract - MRSA, VRE - you name it, she had it. She is allergic to penicillin but ultimately, penicillin is exactly what stopped the infections.
Following a 7-week stay in the ICU while she was battling the infections, the woman endured months of rehab because she could no longer walk. She developed sores on her coccyx and legs which blossomed into full-blown skin ulcers. She was given standard wound care treatment, but it didn't help.
The wound on her coccyx has since healed nicely without any treatment other than frequent dressing changes. The wound on her leg was manageable up until a few weeks ago, when it suddenly ballooned to about 4 inches long. The woman didn't have any fever, though, so the docs didn't think the wound was infected. That was all well and good, except that in the past week and a half, the ulcer has grown to over 7 inches long.
I was not exactly prepared when the resident removed this patient's wound dressings. If you can imagine what a human leg would look like if a dinosaur took a huge bite out of the calf, that's pretty much exactly what the ulcer looked like. It was ENORMOUS and wet and drippy and purulent and the tendons were poking out horribly, though no bone was (yet) showing. Lucky the woman was paralyzed and couldn't feel it - I can't imagine how painful a wound like that would be on someone with good sensation in the legs.
At any rate, the vascular surgeon looked at the ulcer for about five seconds and told the woman that she needed an amputation, pronto. They scheduled the surgery for next week.
Though I'm probably going to have the image of that festering, dripping ulcer in my head for quite some time, I guess experiencing these disgusting things now will only help later when I'll be the one who has to actually touch the patient. Yuck.
Saturday, February 21, 2009
Hospice.
I spent yesterday with a hospice nurse. It was a very sad day, though I did learn quite a bit about what hospice can and cannot do for dying patients.
The nurse, A., was extremely funny and extremely German. She was also the scariest driver I've ever encountered: while I was clutching the door frame and saying my final goodbyes in my head, she was eating macaroni and cheese and driving around rural PA (read: crappy roads) with NO HANDS on the steering wheel. I don't claim to be the best driver either, but the ride was rather more thrilling than I set out to experience when I woke up that morning. At any rate, we didn't get killed, but I was only too happy when we arrived back at the office in the afternoon and I drove myself back to the hospital campus.
Anyway, the day started in the office. For about two hours, A. and the other nurses made various phone calls to patients, mostly to check in with the families and be sure that they were doing okay. After that business was taken care of, A. and I set out to visit a 69-year old man with metastatic colon cancer. The guy and his wife were very pleasant, though he has only been in hospice care for a few weeks, so he was not as visibly ill as I was expecting. The patient stated that his pain was being effectively managed, and that he was able to go about his daily business without too much trouble. A. went over his list of medications, performed a quick physical exam, and changed the dressing on the incision on his belly from his last surgery. It was a pleasant visit to be sure, but it was not exactly what I expected.
The next case was much more what I had envisioned. We visited a rather run-down and unpleasant assisted-care living facility. The patient was a 97-year old man who had been in hospice care for a few months. His condition had deteriorated the previous night, and A. suspected that he had an aspiration pneumonia or other respiratory infection. Whatever the cause, the poor man's breathing was so raspy, it sounded like his lungs were underwater. A. had to leave the room for a few minutes to call the family and she asked that I sit with the patient. I stayed in the room until he fell asleep, but I must say, it was terribly difficult listening to his labored breathing. At one point, he must have shifted slightly and his breathing paused for a second, but my own heart skipped a beat when I heard the sudden silence. For a moment I seriously thought he had died. That wasn't the case; a second later his breathing resumed, but I had to step out of the room and calm down.
Aspiration pneumonia or no, the moment we stepped into that room I knew that the patient did not have long to live. There was just something about the way he was lying there, something so painful about his wasted limbs and rattling breath that made me think his death was going to come sooner rather than later. As it happened, his daughter requested that he begin taking antibiotics to combat his possible infection, but as A. said as we left the facility, she didn't think the medicine would do anything more than make his breathing more comfortable. It was just a terribly sad situation, and I can't say I was unhappy to move on to the next patient.
The final patient was a 77-year old woman with severe congestive heart failure. This patient had been in and out of the hospital multiple times, and though she was not yet a hospice patient, A. was convinced that she was going to need hospice services soon. The purpose of our visit was to check on the woman and to also begin the conversation regarding enrolling her in hospice. The woman was, unfortunately, in complete denial regarding her condition and insisted that she wanted to "wait and see" if her illness improved, and still wanted to "do everything possible" in terms of treatment. A. tried to explain that the only difference between hospice care and the treatment she was already receiving in the ER every time she had a heart episode would be that under hospice care, she would be asked not to call 911, and that the hospice workers would manage her symptoms with exactly the same medications from home. The woman was still unconvinced by the time we had to leave. I had to wonder exactly what her physicians were saying every time she landed in the hospital; surely they knew that her prognosis wasn't so great? I guess end-of-life issues are difficult to discuss with patients who don't want to believe the reality of their situations. I imagine that the woman will be forced to concede soon, as she stated herself that living at home was becoming increasingly difficult and that she needed more help than usual managing her illness.
Anyway, as I said, it was a sad day. I don't think I could be a hospice worker or palliative care physician, but I greatly admire those with the fortitude to help terminally-ill patients and their families.
The nurse, A., was extremely funny and extremely German. She was also the scariest driver I've ever encountered: while I was clutching the door frame and saying my final goodbyes in my head, she was eating macaroni and cheese and driving around rural PA (read: crappy roads) with NO HANDS on the steering wheel. I don't claim to be the best driver either, but the ride was rather more thrilling than I set out to experience when I woke up that morning. At any rate, we didn't get killed, but I was only too happy when we arrived back at the office in the afternoon and I drove myself back to the hospital campus.
Anyway, the day started in the office. For about two hours, A. and the other nurses made various phone calls to patients, mostly to check in with the families and be sure that they were doing okay. After that business was taken care of, A. and I set out to visit a 69-year old man with metastatic colon cancer. The guy and his wife were very pleasant, though he has only been in hospice care for a few weeks, so he was not as visibly ill as I was expecting. The patient stated that his pain was being effectively managed, and that he was able to go about his daily business without too much trouble. A. went over his list of medications, performed a quick physical exam, and changed the dressing on the incision on his belly from his last surgery. It was a pleasant visit to be sure, but it was not exactly what I expected.
The next case was much more what I had envisioned. We visited a rather run-down and unpleasant assisted-care living facility. The patient was a 97-year old man who had been in hospice care for a few months. His condition had deteriorated the previous night, and A. suspected that he had an aspiration pneumonia or other respiratory infection. Whatever the cause, the poor man's breathing was so raspy, it sounded like his lungs were underwater. A. had to leave the room for a few minutes to call the family and she asked that I sit with the patient. I stayed in the room until he fell asleep, but I must say, it was terribly difficult listening to his labored breathing. At one point, he must have shifted slightly and his breathing paused for a second, but my own heart skipped a beat when I heard the sudden silence. For a moment I seriously thought he had died. That wasn't the case; a second later his breathing resumed, but I had to step out of the room and calm down.
Aspiration pneumonia or no, the moment we stepped into that room I knew that the patient did not have long to live. There was just something about the way he was lying there, something so painful about his wasted limbs and rattling breath that made me think his death was going to come sooner rather than later. As it happened, his daughter requested that he begin taking antibiotics to combat his possible infection, but as A. said as we left the facility, she didn't think the medicine would do anything more than make his breathing more comfortable. It was just a terribly sad situation, and I can't say I was unhappy to move on to the next patient.
The final patient was a 77-year old woman with severe congestive heart failure. This patient had been in and out of the hospital multiple times, and though she was not yet a hospice patient, A. was convinced that she was going to need hospice services soon. The purpose of our visit was to check on the woman and to also begin the conversation regarding enrolling her in hospice. The woman was, unfortunately, in complete denial regarding her condition and insisted that she wanted to "wait and see" if her illness improved, and still wanted to "do everything possible" in terms of treatment. A. tried to explain that the only difference between hospice care and the treatment she was already receiving in the ER every time she had a heart episode would be that under hospice care, she would be asked not to call 911, and that the hospice workers would manage her symptoms with exactly the same medications from home. The woman was still unconvinced by the time we had to leave. I had to wonder exactly what her physicians were saying every time she landed in the hospital; surely they knew that her prognosis wasn't so great? I guess end-of-life issues are difficult to discuss with patients who don't want to believe the reality of their situations. I imagine that the woman will be forced to concede soon, as she stated herself that living at home was becoming increasingly difficult and that she needed more help than usual managing her illness.
Anyway, as I said, it was a sad day. I don't think I could be a hospice worker or palliative care physician, but I greatly admire those with the fortitude to help terminally-ill patients and their families.
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