It All Depends on Which End You Are On...

Today, I was reminded that- just like in life, perspective is EVERYTHING.

I found myself once again hanging out with my anesthesiologist mentor in the OR on this fine Thursday. On the docket today, a resection of a breast tumor, a thyroidectomy, and a hysteroscopy with dilitation and curratage. I started a couple of IVs got another intubation, and was reviewing the pharmacology of all of those agents used to keep you from saying "ouch" when a surgeon starts-a-cutting on you. I was having a pretty good day.

The same could not be said of a poor OB/GYN resident.

I am not sure how her day was going but I know for sure it took a marked turn for the worse somewhere around 2:30 this afternoon. You see- at 2:30 this afternoon, a perfect storm of conditions converged. The stars aligned just-so, and her day was about to go south.

The positioning of a patient in the lithotomy position during a gynecological procedure, the propensity for operative anesthesia to relax the body-I mean, REALLY relax the body, the lack of requiring a bowel-prep before such a procedure, and of course the ever-present, gravity- all conspired to ruin our young resident's afternoon.

If you don't already see where this is headed, I'll spare you the suspense. The patient spontaneously evacuated her bowels while under anesthesia. All over the floor. Right where residents (and eager medical students) happen to stand during hysteroscopies. Yum!

It was at this precise moment that I realized: if this had been a few months ago, it would have been my shoes that were under the unrelenting fecal assault, my olfactory bulb sending distress calls to my brain, my gag reflex being challenged, and my face that would be screwed up in a contorted look of pain- but this was not a few months ago. It was today. And today, I was safely out of harm's way. I wasn't staring down the business end of an angry colon. Today I was with anesthesia, where life is good.

It is the little victory that is the most savored!

Honorary Gas Passer for a Week

This week the pajama posse have me scheduled for "specialty week". This week is often referred to by other students who have rotated here as "vacation week" since there is little in the way of actual responsibility and if you wanted to you could easily not show up and hardly anyone would notice. Specialty week is where a student gets to pick from among sub-specialties like urology, neurosurgery, orthopaedics, and anesthesia; to get an idea of what life is like in one of these fields.

I took the opportunity this week to hang out with the Anesthesiology Department- or as they are colloquially referred, "gas passers- owing to the inhaled anesthetics that they administer.

I managed to team up with a pretty good anaesthesiologist who was both laid-back* and likes to teach. I was in the OR mostly all day and did several cases with him including a couple of bronchoscopies, tubal ligations, and a hernia repair. I even got to intubate a patient- the first time I have done that in about 5 years- and this time I wasn't covered in vomit! He took some time to explain what he was doing, but mostly it involved a flurry of work at either end of the procedure and then most of the time sitting around and lsitenting to the monitor beep.

But don't take my word for it:





*Now that I mention it, every "gas man" I meet seems pretty laid-back- I'm sure this has nothing to do with the easy access to all those drugs. My guess is that every Anesthesiologist was, at one, time a budding surgeon- but who didn't make the cut because upon further scrutiny he was discovered to have a soul. (rimshot!)

This Week...

Although I truly enjoy this surgery rotation, it has hampered my free time; and blogging is, unfortunately, one of those things that has dropped precipitously on the: "Things To Do- List". (along with shaving on a daily basis, keeping my liver well-exercised, and knowing what day of the week it actually is!)

Since I only have a short time before the evil sleep-deprivation monster comes to cart me off to the land of the slumbering, here are some random things from this week:

• Yesterday while getting ready for morning rounds I was looking over the OR schedule for the day and noticed a particular theme for many of the cases. There were several hemorrhoidectomies scheduled along with 2 sigmoid colon resections, and a perianal abscess Incision and drainage- all slotted for the day. Before I could compose a snarky joke about this, one of the senior residents deemed the day: "ASS WEDNESDAY". Couldn't have said it better myself! Good for several giggles throughout the day.
• Speaking of giggles... Janki is a fellow AUC student and happens to be assigned to the same team that I am. During our orientation, we were warned of the possibility of a site visit by JCAHO (commonly pronounced "Jay-Co") , the hospital accrediting Nazis. Apparently, someone wasn't paying too much attention- because at lunch on Tuesday, poor little Janki asked the following question, "Hey, when is that Jacob guy coming to inspect the hospital?" It was fortunate I was not drinking anything at the time because this was truly a "milk-shooting-out-of-your-nose-moment". Needless to say I have latched on to her little faux-pas and refer to "Jacob" every chance I get. It has become somewhat contagious and several of us are incorporating a "Jacob" comment (or 3) into daily conversation. Janki has a good sense of humor and is being a good sport about all of this silliness. And no, it will never get old!

On the Family Front:

• Last Saturday Johnny baby-sat his baby sister for me and did an excellent job!- no bloodshed, diapers were changed, lunch was prepared and consumed, and a nap was taken!
• Meagan and Kaitlyn got their report cards recently and Dad couldn't be prouder! Kaitlyn has managed to bring almost all of her (already good) grades up, and Meagan has made the "Principal's List" for getting all A' s.
• Little Miss Rileigh successfully used her new potty for the first time Tuesday night! Since she is only 19 months old we are not "actively" attempting potty training. But because she has learned to notify us when there is a "poopy" or a "pee-pee" we decided to let her get acquainted with the potty. Tuesday night she followed Kathy into the bathroom and wanted to be like her mommy and sit on her potty. Kathy removed her diaper and let her sit on her potty for a couple of minutes when our little "Prodigy of Pee Pee" said, and I quote, "PEE PEE!!!" When she stood up... sure enough she had actually pee-ed in her potty! What followed was nothing short of pandemonium! I was reading in the other room when shrieks of joy were heard almost as far as Connecticut. Keeping in line with the whole "positive reinforcement" thing we made a big deal out of our daughter's physiologic need to empty her bladder. Songs were sung, Dances were danced, and hugs and kisses were.......well...... hugged and kissed.
• My Kids Rock!
  
• Not to be ignored, our little soon-to-arrive bundle of masculine joy is only about 6 weeks (give or take) away from making his debut. It is serious crunch time as far as name selction, and we have nary a "short list" compiled. Feel free to make suggestions in the "comments" section as to a suitable name! Seriously!
  

That is about all of the news-worthy stuff I have for now. Please make use of the comments and let me know that (both of you) are reading this drivel!!

Until next time..........

"Very Nice Man"

So, today I spent most of my day in the surgery clinic. Not a bad way to spend the day I suppose, the cases are varied and we get to work pretty much one-on-one with an attending physician. I worked with two different ones today and both were very good teachers.

Anyway, after being there a couple of hours, I walked into an exam room to meet a new patient and begin my interview/exam, and lo and behold, who was sitting in front of me but none other than Mister Chest Tube. Yup, that Mr. Chest Tube.

He had been discharged from the hospital a few days ago and was there for a follow-up visit and to have his sutures (to close the hole in his chest where the tube was) removed. He did not speak very much English, but through the translator, he told me he remembered me from our previous encounter in the ER and thanked me- not for the whole "johnny-on-the-spot" medical heroics nonsense, I seriously doubt he even remembers any of that and I don't even know for sure if anyone told him what had happened. No, he thanked me for, as the translator said, "being so kind to him".

This kind of shocked me. Since my Cantonese isn't up to conversational snuff, I don't remember our having much of a conversation prior to his little "Waltzing toward the light" act. I must have had a dumb look on my face in clinic today because the patient then explained (again, through the translator) that I had gotten him a blanket while he was still in the ER and that made me a "very nice man". I do remember getting him that blanket because I thought he looked cold and I suppose I got all nurse/dad-like on him and tucked him under the blankets, but I never would have given that a second thought. It is something I have done hundreds of times before while working as an ER nurse.

It is strangely humbling and rewarding at the same time to have him remember this one, seemingly trivial, act and be so appreciative. I have to admit for the rest of the day I would walk a little taller and smile a little wider. It felt good.

I removed his stitches, dressed his wound and in a few minutes he was walking out of the clinic. Odds are that I will never see this man again and I am sure he will not remember me nor what happened that night last week. But I don't think I will forget him. No, not for a long time.

"Very nice man"

Yeah, I'll take that- and you are very welcome, Mr. Chest Tube. Thank you for reminding me what really matters.

Broadcasting Live from the Medical Library...

I am enjoying a rare bit of downtime right now. I scrubbed in on a surgery this morning, saw my patients and wrote their notes, and have shit-all to do right now except study. So why am I writing this stupid blog post you ask? Well, I was about 20 pages into the intricacies of the Billroth I and Billroth II procedures when the center in my brain that monitors abject boredom went off and anesthetized me off into a mid-morning nap.

Right there in the middle of the library. I hope I didn't snore.

So I decided I better take a bit of a break from reading right now and do something useful else. Okay I'm off to visit my patients again.

On-Call Part 2: Saturday Hell

The fine folks of the Pajama Posse who make the student on-call schedule saw fit to initiate me to Saturday 24 hour call the very first week. Yay! Much like my first night on call, yesterday was rather busy. It began at 7am (sleeping-in for these guys!) and we rounded for what seemed like a month in solitary-but in reality was about 2 hours. From there I went back and visited/examined all of the 9 patients I was responsible for and writing their progress notes. Strangely enough this is something I really enjoy. I like talking to the patients, doing a quick physical exam. I then write in their chart my findings, any changes in their conditions, vital signs, lab results, etc. and what the plan is for the patient. Since I have following most of these same patinets this week, we have gotten to know each other and are getting along swimmingly- even when it is Saturday and I am grumpy on the inside. I don't know if it is because I am at a different hospital or just the big differnece between Surgery and Internal Medicine, but I have to admit I really enjoy this rotation far more than any of my others thus far.

After writing the equivalent of a short Tolstoy novel, it was time to head to the operating room to scrub in on the only surgery I would have for the day. A rather minor procedure, the umbilical hernia repair didn't take very long and was over in about 30 minutes or so. I was allowed to put in some stitches, even some of the pretty subcuticlar stitches, which are a bit tricky to do but when done right looks neat and leaves no suture marks. (see picture)

After the OR, my only real responsibility aside from checking in on my patients throughout the day, was to respond to the Emergency Department for Traumas and help out the residents with issues that come up. I thought this would leave me some time to relax and study. Once again proving my ability to be WRONG knows no bounds! I ran around and took care of the seeming endless minor tasks like IV insertions, drawing bloods, putting orders in charts and all the really glamorous stuff medical students do. That's when the Trauma gods took a big dump all over any hopes I had at getting some sleep.

Saturday nights and trauma go together kind of like football players and firearms. There are way too many of them, are usually very stupid, and can have disastrous results.

Last night did not disappoint, there were 7 trauma alerts called. Gunshot to the chest, several patients from a bad car wreck, and the ever popular: alcohol-induced hyper-gravitational state coupled with a flight of 30 stairs. By the time we finished with the last trauma I had exactly 30 minutes to sit down and try to close my eyes before it was time to make the rounds on all of my patients quickly, update their vital signs and labs, and be ready to round with the on-coming Sunday team. This took me to about 8:30am; a mere 25 1/2 hours after I walked in. I passed out at home around 9:30 this morning and slept the sleep of the dead until about 5pm. Now I have to try to get back to bed early tonight since I am due back at 6am. Next on-call night...Thursday! Oh boy! I can't wait.

Welcome to Surgery...Now Grab Your Ankles!

Perhaps this is not what was said to us during our orientation session, but it should have been!

I didn't expect rainbows and unicorns on this rotation by any means, but it was certainly "more intense" than even I had imagined.

I was warned by other students that the On-Call** phenomenon begins on Day One so I was not entirely surprised to find out that yours truly was not going home after his "entirely adequate" orientation. No, the Pajama Posse had big plans for this medical student.

My day began Monday at 9am for orientation and didn't end until 8am this morning (Tuesday).

To say that my first day with the fine folks of the surgery department was a baptism by fire would be a rather large understatement. By the end of my shift this morning,

I:

• Responded to 5 of the 8 trauma alerts (I was in the OR during the other 3)
• Scrubbed-in on 2 surgeries: a fairly simple skin-graft, and a pretty cool pericardial window surgery. For those who don't know, this procedure involves cutting the membrane that encases the heart to drain blood or fluid from the space surrounding the heart. Scalpels only millimeters away from beating hearts, yeah, pretty cool.
  
• Put in a couple of IVs
• Drew an ABG
• Stapled a head laceration closed
• Saved a man's life.
  

Now before you think that I have already assumed the pajama posse's infamous God Complex, allow me to explain: I was assisting a resident in placing a chest tube(see picture below) in a patient who had developed a spontaneous pneumothorax. During the procedure the resident was being very accommodating and teaching every step of the way. There was a point in the procedure when the patient (understandably so) began moaning from the pain. Out of habit, I happened to look at his cardiac monitor and noticed the patient's heart rate was now 47 (a bit on the slow side if you are keeping score) I mentioned to the resident that his heart rate was now 47 and I think he was having a vaso-vagal response to the pain. As I was saying this, his heart rate dropped to 43....38....34....20....then single digit badness. I think I scored major brownie points with this particular resident because I not only "noticed" that the patient was attempting to join the choir invisible, but I remained calm and jumped into action calling for a code cart, grabbing my own medication, and administering Atropine in the span of seconds. After a brief run of CPR the patient's pulse returned and would soon be awake and thanking us. Afterward, I apologized to the resident for what may have been seen as 'over-stepping' my role as a medical student, but she was very appreciative and thanked me repeatedly for stepping up. I think I made a friend.

Not bad for my first day!







** For the uninitiated, On-Call is what the hospitals now impose on its residents in the aftermath of other, more colorful, draconian methods of torture having fallen out of favor or having been campaigned against by Amnesty International. There is no good reason that medical students need to be On-Call, by the way. I suppose it is just a combination of initiation/hazing to, you know, get us acclimated to the suffering; and a brief respite for the beleaguered residents to have eager students around to help them complete the endless list of doctor-ry things they are required to do every night that the On-Call demons have them chained to the grindstone. Misery, that promiscuous whore, loves company I suppose.

Groundhog's Eve

Well here I am on the eve of not only Groundhog's Day, but the begining of the much maligned surgery rotation. I have to admit I am not really looking forward to the hours and I am not entirely thrilled with the speciality. I will however try to keep an open mind and make the best out of it for the next 12 grueling weeks. On the bright side, I am looking forward to being productive outside the house again. Although my wardrobe will only slightly improve from my daily "comfy" pants to scrubs.

Stay tuned...