In a shade over 169 hours I will be frantically logging on to a website to find out if I "Matched"*
It feels surreal that all of the work and sacrifice leads to this one moment next week that will determine the rest of my career. But, I suppose that life is just a series of these moments. I am strangely calm at the moment but my serenity is occasionally punctuated by brief moments of sheer terror. Stiff upper lip and all that..
* I have received a bunch of questions about the whole match process so I have decided to include a overview on how this whole thing works. I hope this helps.
Every year medical students graduate from medical school and subsequently begin their Residency training.
Residency is where physicians complete several years of training in their chosen specialty. This training, is for instance, where family doctors become family doctors, surgeons become surgeons, and psychiatrists become weird. (I kid because I love!) Prior to residency, we are all pretty much the quintessential lump of clay which requires a great deal of molding (preferably by a scantily clad Demi Moore while Unchained Melody plays in the background...but I digress...)....where was I ? Oh, yes- molding- right. In order to become anything resembling useful physicians we need residency training.
So how is it decided who will become surgeons and who will become OB/Gyn etc. ? (fighting the urge to do a 'head-injury' joke here) Well, we get to choose.
Sort. Of.
After doing some soul-searching (no offense meant, surgeons) each one of us decides which area of medicine we would like to pursue and then we apply to residency programs in said specialty. For some, deciding on a specialty is one of the hardest steps in this whole process- lifestyle, salary, work environment, patient population, competitiveness of the applicant, and about a million other factors must be carefully weighed so each student can figure out which specialty suits their preferences best.
Step 1 : Drowning in a sea of paperwork (July-Sept)
The July of medical student's 3rd year they begin working on their applications to residency programs. Transcripts, Letters of Recommendation, personal statements etc. are all gathered and submitted to ERAS a central web-based application service. Beginning in September, applicants choose which programs to submit their applications to. This is a fairly simple matter of selecting programs from a list within your specialty and clicking on a box. ERAS takes care of the rest (transmitting all of your application info to each program).
Step 2: Waiting is the hardest part
After an applicant's applications are sent out, begins the waiting phase. Each program has its own unique timetable to do things so this is an anxious period. Programs review applications and based on what they are looking for choose which applicants to invite for interviews.
Much angst surrounds exactly how programs choose which applicants to interview. Is it test scores- is there a cut-off number? What about personal statements? What about my letter of recommendation from my High school guidance counselor/ Psychic/ Oral Hygienist? If you are looking for a great source of entertainment hang out in the cafeteria in September and sit at a table full of Medical students. You will learn that, "according to my friend's girlfriend's roommate's uncle- who is the program director's gardener...." that the actual process used by programs to select applicants to interview is a proprietary blend of alchemy, remote viewing, dark magic and the use of a random number generator. Good Luck!
Step 3: 12 cities in 9 days? Sure I can do that! (Sept-Jan Interview Season)
Once applications are submitted, slowly but surely (hopefully) invitations for interviews will start rolling in. This is an exciting time- you have at least "made the cut" and the program has an actual interest in meeting with you. Applicants will begin traversing the country in a whirlwind manner and doing their best to make great impressions with each of the programs they interview at. This is the opportunity for each applicant to see the program up close and personal, kick the tires, talk to the current residents, and see if they would like to spend the next several years there. The flip side of this, of course, is that from the program's point of view it is a chance to discover the hidden sociopathic pathology that your personal statement glossed over. I was actually told on an interview, "We just want to make sure you're not a douche."
Step 4: I like you...as a friend
After all of the interviews, each applicant has an idea of which of the programs they liked the best and begins to formulate a list of their top choice, second choice etc etc. Using another web based computer system, the National Resident Matching Program, NRMP, each applicant actually submits their Rank Order List, ROL. In turn, each program will similarly rank each of the applicants it has interviewed. Yes, they actually rank in order the applicants they have interviews in order of preference. This year's deadline for submitting your ROL was February 24th.
Step 5: THE MATCH.....The answer is: ...... 42
The last step is the most exciting. Armed with each applicant's ROL, and each program's ROL the NRMP computers follow an algorithm to "match-up" applicants with programs, hence the name. For those who will be applying next year, do yourself a favor and check out the link explaining how the algorithm works- this is another one of those pet topics that medical students seem to have nothing but misconceptions about. (For the last time, spelling out obscene words using the fist letter of each program on your ROL will NOT GUARANTEE YOU A SPOT at John Hopkins Dermatology!)
This year on March 15th at 12:00 noon EST the results of this Matching algorithm will be made known!
Sort. Of.
March 15th each applicant will find out IF they have matched with a program or NOT. Applicants will not find out WHERE they have matched until March 18th.
Why the built-in days of agony? The interim period is known affectionately as The Scramble- this is an opportunity for those applicants who have not matched to a program to have access to the still-unfilled spots at various programs and serves as a last ditch effort to secure a residency spot.
I hope this helps to clear up some of the questions regarding this whole process, like:
"Have you mathced yet, Vince?"
"Where are you going to be working, Vince?"
"Why are you curled up in the fetal position, Vince?"
Earlier this week I began what will be my final rotation of medical school.
It sounds weird. My LAST rotation! Yes, in just a few short weeks I will finish medical school. The reality hasn't fully set in yet.
For those who are following along at home, when last we left our hero he was up to his pons in reflex hammers and MRI scans during the Neurology rotation. After 4 weeks of diseases of the brain and nervous system, I began Hematology/Oncology.
This was not a very enjoyable rotation for a few reasons, not least among these was the rather depressing nature of seeing patient after patient in the throes of their terminal illness. It becomes almost surreal after a while. It was interesting to observe how different physicians interacted with the patients. Styles varied but most seemed to deal with the death issue very well. One can learn a great deal just being around people I suppose. From a medical student perspective, the rotation was fairly educational and the attendings were laid-back and focused on teaching. The schedule was rather long and most nights I was there way longer than any self-respecting 4th year with senioritis should have been.
Anyway, that is all behind us now and this week I began ...I'll say it again...my final rotation of medical school- Endocrinology.
So far it is completely enjoyable. There are only a few disorders that make up the lion's share of the patients we see- Diabetes, Thyroid derangements, the occasional pituitary abnormality nothing too exotic so far. The management is pretty straight forward and not too mentally exhausting, even for a medical student. Our attending is quite personable and has an excellent rapport with both his patients and his students. He seems never to be at a loss for a story, ready at a moment's notice, to illustrate a point, or teach a lesson. Most are pretty amusing . Tuesdays are spent at his private office in the heart of Brooklyn- quite an interesting experience.
Each of his patients seemed to come straight out of Central Casting. More caricatures than actual people, I half expected to hear a laugh track begin playing after each question and answer exchange, or perhaps a rimshot.
Some of the actual exchanges between our attending and his patients :
So what brought you in today?
"The bus"
And how do you take your metformin? ( a diabetes pill)
"Orally"
You have diabetes, high cholesterol and high blood pressure; is that right?
"No I don't HAVE high blood pressure- I GIVE high blood pressure, I'm a carrier [points to his wife]
...and so it went.
Each patient seemingly trying to outdo the last in this Vaudevillian banter. I'm not sure if it was just the patient's personalities, or the fact that they had an audience in us [the medical students], but I suspect that this was part of the normal relationship our attending has with his patients. It was nice to see. Quite a refreshing change compared to my last rotation.
I realize I haven't posted in a while and have yet to mention anything about the whole applications/interview process- stay tuned. I apologize to the 3 of you who actually read this and may be interested in such things.
More posts are coming soon. Really. I mean it this time.
Trust me, I'm almost a doctor!
This week in GI, I am doing consults. It is a nice change of pace from the non-stop onslaught of colonoscopies and esophagogastroduodenoscopies. Basically, whenever one of the managing medical teams decides that their patient has a problem that may benefit from the GI service they request a consult. It is the medical world's equivalent to "Hey take a look at this and tell me what you think". There is a fair amount of consults that come into the GI service everyday so they are only too happy to let the medical students "help them out". Anyway, during a lull in the consult action I was asked to head back to the endoscopy suite to lend a hand. I was soon joined by another medical student and after taking some H&Ps we were observing a fairly routine colonoscopy.
The endoscopy suite resembles a small operating room. There is a large video monitor on the wall, a stretcher in the middle of the room, the endoscopy machine is stacked neatly on the counter, and a full array of tools, wires, hoses, and scopes are hanging neatly on the wall. The thing that makes the endoscopy room a bit different is once the procedure begins the lights are all turned down really low. I made a joke my first day there that at least they provided a little mood lighting before impaling you with large medical instruments.
Having music playing in the operating room is a fairly common thing. Many surgeons have their "pet music" that they need playing in the background while they snip and hack through tissue practice their healing arts. The endo suite is no different. Most of the doctors there are content to leave the radio on; tuned to some "office-appropriate" adult contemporary station.
The low lights, the music playing in the background, and my somewhat twisted sense of humor came together in a perfect storm today that almost had me laughing out loud.
In the middle of a procedure that involves passing anywhere between 4 and 6 feet of unfriendly colonoscope into your "Holyiest of Holyies", I happen to catch the song that was playing on the radio. I tried to stifle a giggle as I looked over at the other student and told her to listen. As luck would have it, Marvin Gaye was crooning on about his need for Sexual Healing.
And then came this lyric:
"You're my medicine. Open up and let me in.
Darling you're so great, I can't wait for you to operate.
I can't wait for you to operate. Baby, I can't wait for you to operate."
I guess you had to be there.....
If my life were a movie, this is where the Big Training Montage scene would go.
With only 6 more studying days until my big fight test, the studying has been in high gear for a while.
Actually, it is almost around the clock, literally. Between my usual dose of insomnia and Dylan's 2 middle-of-the-god-damned-night-feedings while Kathy is at work, I find myself watching review videos or reading by computer light while the little guy hungrily chows down a bottle. Afterwards, as I toss and turn, trying to fall asleep, I will inevitably think of something I wanted to look up or a practice question I got wrong. It will fester until I eventually give in to my compulsion and... out come the books.
I have been at this pace for a good while now and I seriously can't wait until this particular test is in my rearview mirror.
You always hear about the Herculean effort and multiple sacrifices that are needed to get through medical school. I wasn't naive. I understood what kind of work it was going to take. I knew what I was getting into. I entered into this journey eager, and with eyes wide open. Don't get me wrong, there have been a bunch of sacrifices and our road was not without its share of bumps, but frankly, I never felt like this whole thing was that bad . I'm not sure if it is because I have a supportive family around, or because I had a good bit of clinical experience before starting, or just that I am too damned old to get flustered about things. Whatever the reason, I had it all under control. Things, they are starting to change.
I am sure this is a very common feeling for most students around this time in their careers. So close to the end (or beginning, actually) and each next step is a bit harder to take. The feeling like it is NEVER going to end, and the mountains of tasks- still left to be done.
Yes, I am so ready to get this test over with and reclaim just a small part of my life.
So, if you are in the neighborhood of the Prometric Testing Center in Manhattan next week, and you spot a man with blood-shot eyes, sporting a "playoff beard", who smells of regurgitant breast milk and baby powder, mumbling to himself manicaly, "Yo, Adrian!", as he walks out of the building- just smile and nod and let me have my moment- I've earned it!
Friday night was my last shift of my Emergency Medicine rotation. Unfortunately, it went out with a whimper and not a bang. My last 2 shifts there were uncharacteristically slow. I suppose that is a good thing for the citizens surrounding the hospital, but not necessarily how you want your shifts to go when you are an eager medical student. (paying not a small sum of money to 'get your learn on') The whole rotation went really well however, and it has been the most enjoyable rotation by far. I am looking forward to another ER rotation assuming I can successfully schedule one.
With only 5 months of rotations left, I am starting to see the light at the end of this tunnel. It is a pretty exciting time. I must admit my excitement is tempered a bit by the stress of all that remains left to do. There are personal statements to write, lists of residency programs to weed through, letters of recommendations to secure, applications to fill out etc. The seemingly endless administrative tasks are the bane of my existence, but a necessary evil so I'll stop whining now.
Before I can dedicate the time needed to get my applications in order, I have to tackle the USMLE Step 2. August 10th is my test date. I have been trying to study as much as I can and have been doing practice questions for almost 2 months now- squeezing in a block of questions whenever I could. Since I am rotation-free for the next 3 weeks, my studying will ratchet up to a full-time job (in addition to my Mr. Mom duties while Kathy is at work) so this should be a very interesting few weeks. I have been doing pretty well so far on the practice questions and I did well on the sample exam that you can download from the USMLE site; so far so good.
While I am fairly confident going into this exam, everyday it seems I uncover yet another piece of medical knowledge that yours truly has simply... forgotten. The information is gone and all that remains is the phantom of a memory, mocking you, like a dream you can barely remember. The harder I try to recall, the fuzzier the details get until I find myself at my desk drooling on myself and realize half an hour has passed. I realize that no one is expected to remeber everything, and I'm sure everyone has moments like these, but it is of little consulation when you feel the cruel grip of senility taking hold. Studying for an exam like this is quite the gut-check. I think half the battle is hanging on to your sanity.
I have a particular mental block when it comes to a few topics, try as I might they slide through the steel trap sieve that is my mind:
The glycogen storage diseases- once upon a time I could prattle on about them, now... nada.
The serological markers and the auto immune diseases they are associated with- anit-dna, ana, anti-centromere, smith, rho, jo, anca...calgon take me away!
The congenital adrenal hyperplasia enzyme deficiencies- 11, 17, 21...22 23 whatever it takes. ( I have drawn the chart about a bajillion times over the last 4 years- you think I would remeber... any of it!
The relationship of gnrh, fsh, lh, estrogen and progesterone in the menstural cycle/pregnancy. This one I can usually recall after a mini "drooling session" but it seems that my lack of understanding of women doesn't end with The Mystery of the toilet seat left in the UP position and the psychotic break it precipitates in those afflicted with 2 X chromosomes.
By no means is this list complete, the sheer weight of what I don't remember would sink the QE2.
Despite my selective amnesia, I push on, ego in tatters, and like Sisyphus, I am condmened to watch the boulder of my memory roll back down the hill. Maybe today some of it will stick.
Maybe.
Things have been a bit on the busy side. I have switched to night shift in the ER for the next 2 weeks and have been struggling to get used to being awake all night again. Things are going really well on this rotation and time is flying by- as I imagined it would.
This was a case I had last week. I saw a gentleman with a bad venous stasis ulcer who had just been discharged from the hospital. He was returning because the ulcer had just started to drain some rather purulent material despite being on some antibiotics. After taking his history and doing a physical I went and looked in the computer system for a x-ray of his leg- since he had an old distal femur fracture that he chose not to have repaired for some reason. I saw the x-ray and it was quite an impressive fracture but other than that, the area of his leg where the ulcer was looked pretty good. When I presented the case to the attending I mentioned that I would like to get another x-ray even though the one on file was less than a week ago. He agreed, and I ordered the films. A little while later I went to pull up the x-rays and this is what I saw:
Click on the images to enlarge them, if you are having trouble seeing, there is subcutaneous air in the soft tissue.
Diagnosis: Gas Gangrene. Pt was scheduled for amputation of the leg above the knee for the morning.
Reason # 419 to keep your diabetes under control.
Today I began my 2nd week of Emergency Medicine with an all-day student lecture marathon. They rotated in several of the residents/attendings in throughout the day and each one conducted a lecture. The topics were pretty good for the most part, but sitting a very warm and stuffy room for 8 hours is not my idea of a good time. Tomorrow I am scheduled for the 7am-7pm shift I suppose it will go by much faster than today did.
Tonight is Kathy's first night back at work since having Dylan; and we have recruited Kaitlyn to come up and lend a hand watching the kids in the overlap between when I leave for work in the morning and when Kathy gets home. Rileigh is thrilled to have her big sister here to torment play with! So far Dylan seems to be cooperating, and hopefully we will all get some sleep tonight.
Speaking of sleep...
Last night I spent my shift in the "Urgent Care" area. Every hospital has its own nomenclature- but this falls somewhere between the "Fast Track" and the "Acute area"(where I spent my first shift) in terms of acuity. The Urgent Care area is where patients with a low likelihood of admission are seen- but who still may require some type of work-up / intervention. I was stationed there with one other student, a resident, and of course, the attending physician.
It wasn't incredibly busy, and my first impression was that my evening would be spent with a lot of down time; and not much in the way of learning on this particular night. So, I decided to make the most of things and grabbed a copy of Blueprints in Emergency Medicine, 2nd edition and proceeded to do all the questions at the end of the book in between evaluating patients*.
There was a fairly steady flow of patients and I was able to see my share throughout the night. Granted, they had nowhere near the acuity of the previous nights' patients, but that is the nature of the beast. Fortunately, the attending physician was into teaching and began early-on with the interactive teaching sessions.
Several topics were covered including the management of the acutely intoxicated patient( and legal ramifications thereof), the differential for invasive diarrhea, and the evaluation of shoulder injuries. Since I am the whipping boy sub-intern, most of the questions were directed straight at me. I was feeling pretty confident since I was fielding them without any trouble at all. This of course was about to come to an abrupt end.
The patient in question was a female in her 30's who sustained a small laceration to the tip of her thumb 4 days ago. She was prescribed an antibiotic by her primary care doctor 2 days ago, when the thumb began to swell and became more painful. I conducted a brief history and exam. The thumb did not look that bad, there was no local collection of pus, and there was only minimal restriction of her range of motion while sensation in her thumb was not grossly affected. I was working on a diagnosis of local cellulitis. After quickly confirming the absence of any fevers or drug allergies(I was anticipating a change in antibiotics) I was on my way back to the attending to present the case to him. [Cue Chopin]
After what I thought was a rather complete and concise presentation, the attending said, "Let's go see her." I thought I detected a certain glisten in his eye.
The attending introduced himself to the patient and proceeded to put her through a very similar physical exam that I had just conducted. After which, we went back to the witness stand desk where the questions began:
Attending: So, what is your diagnosis?
Me: It doesn't look like an abscess, I think it is just a mild localized cellulitus**.
Attending: Mmm Hmm... [this is never good] So, what would you be concerned about given the location of the injury?
Me: umm...err...duh....I suppose It could to progress to a Felon ?
Attending: OK fine, that is right it could, but what would be a serious complication of her wound? [holding back frustration in a not-so-subtle-way]
Me: I suppose it is unlikely, but perhaps osteomyelitis would be fairly serious.
Attending: [doing his best to fight the overwhelming urge to call my lineage into question] That would be "rare". Have you ever heard of Tenosynovitis?
Me: [cue crickets chirping... as I desperately apply my "conversational Latin skills" to the problem] That is inflammation of the..uh.. tendon..[trailing off] and the... synovial space?
Attending: [wearing the look of a chess grandmaster who sees imminent victory] Close-But. Why dont you go ahead and look that up for me- and tell me Kanavel's 4 Cardinal Signs of Tenosynovitis, why it is important, and the management. I'll give you 5 minutes, then you will tell me. And then you'll teach the 3rd year when he comes back from seeing his patient.
Me: Uh, Sure. [I like this guy]
Needless to say, I looked up all there is to know about Tenosynovitis and was able to sucessfully answer the question, and proceeded to teach my fellow student about the diagnosis and management of the dreaded, Tenosynovitis. Thankfully there was a 5-Minute Consult on the bookshelf.
I have to say, I think it will be a good long while before I ever forget to consider that diagnosis again.
Tuiton for clincial roatations: ~$1000.00 per week
Cost of Dansko Clogs (inserted firmly in the mouth): ~ $90.00
Having your ego kicked in the nuts- but actually learning something that may save a finger or a hand someday: Pricelesss.
*If you are interested, there is a typo in the answer key- answers #33 and #34 are transposed.
** For the record, my diagnosis was correct; but I was wrong not to consider( or even know about) the more serious differential.
Picture credit: Wikipedia
At long last, my Emergency Medicine sub-internship has started. Last night was my first shift and despite what Tom Wolfe said, it was EXACTLY like going home again!
Home- assuming your home was a chaotic, loud, disorganized, subterranean outpost of the hospital where the teeming masses of the sick and injured (and not-so-sick-or-injured) are congregated on stretchers that appear to be engaging in some constant breeding program and occupying just about every square inch of real estate. If your home is filled with the cacophony of ringing phones, beeping monitors, wailing patients, colorful language and smells like a cross between a Calcutta sewer and a North Philadelphia manhole cover, then yeah- it is just like home.
I can't believe how much I have missed this!
My shift started at 3pm. There were several students there some 3rd years and some 4th years. We met with the attending who was working that evening and since he is also the administrator in charge of the medical students, he gave us a brief orientation. It was your basic "Welcome to the ED" kind of orientation, but he did tell us that they expected a bit more from the 4th year students doing the sub-internship. They expect us to be completely be involved in all aspects of our patient's care. They made a big emphasis on procedures as well. The 4th year students are supposed to get the first shot at any procedure that their patient may need, central lines, intubation, sutures, etc. More important than this in my opinion, is that we really are expected to function at the intern level. We see patients independently, come up with a differential, formulate a plan and then present directly to the attendings. We then go back and "do" all of the things in our plan: if the patient needs an IV we insert one, if they need blood-work, we do it, ditto Foley catheters, NG tubes et cetera, et cetera. This is probably done just as much out of necessity as it is for educational value. There is a high volume of patients and there is only a finite number of nurses. So I suppose it works out for everyone.
After our brief orientation I was handed a chart and told to see my first patient. A patient that the test writers at Step 2 CS would love! ( I promise I will post about my CS experience very soon) She had symptoms that easily covered about 5 diagnoses. A great medical student case.
My next patient was a woman who elderely woman who only complained about "not feeling well". She was not the most easy pateint to get info out of and kept saying very ambiguous things like "I am just not feeling up to par". After a long list of questions from me including her opinion on East coast versus West coast Rap, I was only able to get her to admit to slight shortness of breath. OK on to the exam. Lungs: rales at the bases..hmmm. Heart: systoloic murmur, irregular and kinda quick...the plot thickens. Of course she was in a A-fib with rapid ventriclular response with a rate of about 160. Interestingly enough, after some rate control with cardizem her CHF got worse and she teetered on the intubate/no intubate fence for a while before she finally started to improve.
Not to be outdone, my very next patient was an 80ish year old man sent from a nursing home for evaluation of an isolated extremity injury, seemingly a pretty mundane case except when his EKG printed out:
The patient was asymptomatic (as much as an 80 year old demented man can be asymptomatic).
Not a bad way to start a shift. I got to do a bunch and saw some pretty high acuity for my first night there.
I entered med school with the idea that I wanted to do Emergency Medicine. I did try to keep an open mind and stay receptive to the possibility of another specialty, but nothing is as satisfying to me as EM. For me, I suppose the choice was made long ago. But if I was on the fence about what to do, last night would have sealed the deal- not because I saw some interesting patients or the 'excitement' of treating a high acuity case. For me the thing that stood out was how comfortable I felt to be back in an ED doing what I think I am meant to do. It was like putting on a very comfortable broken-in pair of jeans.
To the uninitiated, the ED must appear simply chaotic where there is no chance of anyone receiving anything even approaching decent medical care. With stretchers packed in one practically right on top of the next and only a thin curtain to distinguish where one patient's "room" ends and the next one begins it must look more like some makeshift M*A*S*H unit from days gone by, than a modern American hospital. Despite all of this, if you watch closely enough you start to see some order in the chaos, and somehow, however unlikely, people are cared for and the staff seems to have a handle on what is going on. Make no mistake, the ED is not without its share of problems and given the current state of health care in this country is likely to be one of the targets for any real reform.
Emergency medicine is not perfect, far from it, I know; but somehow (perhaps because I am so very far from perfect) I feel like we are perfect for each other.
I am actually looking forward to my shift tonight. Sick, I know.
Yesterday I spent the day in the Interventional Radiology Department. The IR department is a pretty cool place where technology and medicine collide. In short, they use cutting edge imagining techniques to assist them in diagnosing, and more importantly, providing treatments in the form of various procedures.
I got pretty lucky yesterday since there were a wide array of cases. There was a femoral and aortic angiogram, a percutaneous drain placement in the gallbladder, a kidney biopsy, and very interesting catheter thrombolysis of 2 whopping Pulmonary Emboli. I was told by the Radiologist just how fortunate I was since they do not do too many of these procedures- he guessed maybe only a dozen or so last year- since clots of this magnatude are usually fatal.
The patient was a previously healthy woman in her early 70's hwo presented with shortness of breath. It was discovered that she had massive bilateral PE's; the one on the left was occluding just about 100% of the pulmonary vasculature. Basically only one of her lungs was working at all and it was pretty compromised at that.
The procedure we performed yesterday involved placing a long catheter in her femoral vein and threading it up through the right side of her heart and into the left pulmonary artery. Although I have known for a long time about the capabillities of IR, it was still nonetheless impressive to see it done right in front of me. The neat part involved using a specially designed catheter (threaded to the same place) that had the ability to 1) deliver TPA (a clot dissolving agent) directly to the clot and 2) consisted of a internal core wire that plugged into a machine the size of a small carry-on suitcase that caused the internal wire to emit very high frequency pulsations- in an effort to physically break op the clot. This was to be left in place for a number of hours and then another catheter would be used that alternates very rapidly shooting saline solution and suctioning it back out- in essence pressure washing and vaccuming out the clogged artery.
Although this procedure carries a fairly high mortality with it somewhere around 15-30%(given the very sick nature of the patients who need it along with the risk of complications etc.) the pateinet did well, at least until I left for the day- She was still in the letting the catheter vibrate out her clot phase of the treatment.
I was rather impressed with my day spent with the IR guys. I recommend it to anyone who has the opportunity during your rotations.
Below is a picture I snapped with my cell phone of the IR control room. In place of the standard white plastic light difusers you see all over the hospital that cover the flourescent ceiling lights this is what they have in IR. I guess they have a few more dollars in the old budget for "ambience".
I survived another 25 hour shift on-call Saturday and slept the sleep of the dead today. I am having some weird experiences lately with having a tough time separating things that actually happened and dreams I have when I am extremely tired. Is this the begining sings of psychosis? I hope not. Most likely I have been just really tired and having very realistic dreams lately.
Although it was fairly busy last night, there was not too much in the way of terribly interesting cases. I scrubbed in on an appendectomy and a cholecystectomy during the day yesterday and the OR was fairly quiet besides those cases.
Last night we had several traumas including 2 gun shot victims. Somewhere around 3am this morning a young woman in her 20's was brought in with a gunshot wound to the side of her neck with an exit wound to the opposite shoulder. Since she was fairly stable for the moment we took her to get CT scans to further evaluate her injuries. She later went to the OR for exploration of her wounds and did quite well and is recovering today.
While we were waiting for the scans to complete I asked one of the other students with me, Dave, if he had noticed the tattoo our patient had in her arm. He had not. I explained to him it was a picture of Winnie the Pooh sitting holding an overflowing honey pot with bees circling around. The caption above and below the picture read:
"Get Rich or Die Trying".
To which he said, "So far its Get Rich: 0, Die Trying: 1" (giggle-snort)
To no one's surprise, we get along pretty well.
Despite being the first day of spring I woke up this morning to snow flurries grrrr. I am ready for some nice weather, this winter-although not too horrible- has seemed to drag on forever.
Today I was scheduled to be in the surgical clinic and it turned out to be a pretty good day. I got to do an Incision and Drainage of a pretty nasty abscess, but taking the prize today....
I saw an interesting man with an even more interesting hernia. The patient was a 72 year old male who came in for evaluation of a suspected hernia. I began asking him a bunch of questions and somewhere during my little interview he told me he is remarried and has 2 children with his new wife. I must have had my "big fat hairy deal" face on because he seemed to be waiting for some sort of reaction, after a few seconds he then proceeded to tell me their ages [drum roll please]...............4 and 3. Years. Holy Tony Randall, Batman! I could feel my facial expression change into my "you've gotta be shitting me!!" face but I couldn't help myself. Apparently, his hernia has not affected the Michael Phelps-ian ability his own 'little swimmers'.
For some reason all I could hear in my head was the haunting, "VIVA....... VI...AGRA" song playing over and over!(it's a curse.) He then dropped this little pearl in my lap:
"I don't go to the gym, I go to the bedroom!"
Now all my head could do was hear a Budweiser Real Men of Genius commercial playing:
Here's to you, Mr. Getting it on and cranking out kids as a septuagenarian......While other guys your age are trying to shoot pool with a rope, you're long, strong, and built to get the friction on!
I dont think I heard much of what he said for the next several minutes, as I was still composing the Budweiser comercial in my head. (Im telling you, it is a curse!) I finally got around to the physical exam and I was equally impressed by the size of his hernia! It was, in medical parlance, Friggin HUGE!
After a few more questions I discovered that he forgot to mention that he had had a CT scan done recently, so I excused myself and went to talk to my attending. I pulled up the CT scan and lo and behold: a whopping hernia. Only this hernia contained a goodly part of his bladder that was hanging out of his abdominal wall. Impressive! He is scheduled for surgery that will invole a Urology surgeon as well as a general surgeon to repair this.
So, godspeed, Mr-Works-out-in-the-bedroom-at-the-age-of-72! I hope the recovery doesn't hamper your um.........ahem... 'exercise'!
Tomorrow will be the end of the 6th week of my Surgery rotation, the halfway point. Time sure does fly. All in all, it's been good. Sure, I am getting up at a wholly demonic hour, and feel like a very old man every night- but the rotation has been interesting.
Since last Monday, I have been on the Trauma team again and therefore did not have to take on-call shifts this week. That all ends this Monday. The trauma bay has been unusually slow this week and the traumas that came in were not incredibly serious. I did get to suture some poor soul's head laceration which bore a striking resemblance to a large Mercedes-Benz logo. (if it were drawn by a Parkinson's patient)
Just like on TV, the ER was incredibly busy and there was "no room at the inn;" so I got to do my Betsy Ross impression right there in the hallway. I did a pretty good job and was feeling pretty proud of my handiwork- the resident came over and looked at the now handsomely-closed wound gave it her blessing. Yup, I was feeling pret-ty proud of myself...until.
Since I was suturing him in the hallway I used a basin to catch the fluid I used to irrigate his wound with and when I was done instead of taking the extra minute to go discard the bin full-o-stuff, I set in down on the floor next to the counter. Of course everyone knows that: basins full of urine, feces, vomit, or bloody-saline and betadine have mystical magnetic properties! During my cleaning up- I was throwing out all the supplies I used; and right before I was finished- I kicked the basin over and splilled it ceremoniously all over the floor! Dumbass! Lesson learned.
Basin: 1 Ego: 0
Yesterday I scrubbed-in on my first "marathon" surgery. It was by far, the most interesting thing I have seen. It was an Ivor-Lewis Esophagectomy***, and required two surgeons to work in concert- one in the chest and one in the abdomen.
This procedure is done to remove a diseased portion of the esophagus (the tube that connects your mouth with your stomach. The disease is usually Esophageal Carcinoma). It is fairly complicated and done in several steps- that on their own, could be considered a surgery unto itself; but I will attempt to simplify:
Typically, a large incision is made in the abdomen and the goal here is to "free-up" the stomach. This means separating the blood vessels, and connective tissue attchments. Then through a thoracotomy incision, the stomach is pulled up into the chest cavity. The diseased portion of esophagus is cut out. After some creative work by the surgeon trimming the stomach down to become a "replacement esophagus" crudely speaking, the cut ends are sewn back together.
Several factors made this particular patient's surgery more complicated. For starters, the abdominal portion of the surgery was done via laparoscopy- No small feat considering all the work that needed to be done. Secondly, a series of equipment problems seemed to plague the surgery to such an extent, that toward the end of the surgery, it looked like the scrub nurse had some sick type of Noah's Ark fetish, since there were 2 of everything crowding the room : video monitors, laparoscopes, harmonic scalpels, electro-cauteries, et cetera, et cetera, et cetera.
The surgery began at 10:20am and lasted just shy of 12 hours! I would love to tell you I hung in there for the entire thing, but I would be lying. There were 2 medical students scrubbed-in on the case and we were offered after about 5-6 hours a "break" to scrub-out, grab a drink or use the bathroom. We both refused since the case was very interesting. (and we are both closet masochists) However at hour 10 1/2 my bladder had ideas of its own and I gracefully bowed-out.
Standing for 10 1/2 hours in an OR, gowned and gloved, is no small task- I assure you. I now have an even greater appreciation for those surgeons engaged in these sorts of procedures.
I still think I am destined to beocme an Emergency Room physician, but if it were not for my age, family status, and presence of emotions, I could certainly see myself becoming an entirely adequate surgeon.
Oh, I almost forgot, the title of this installment of inanity.
It took me several times before I finally caught on, but the surgeons kept referring to the "goose", as in "this is goose", or "the goose should be free now". Aparrently, in surgeon-speak the "goose" is esophagus; as in, "esopha-goose".
It seems the cyborgs possess a sense of humor....hhmmm.
I spoke to a fellow student who is working in the Surgical Intensive Care Unit and I was pleasnatly surprised to learn that this patient is off the ventilator,awake, and is doing reasonably well for being a hexagenarian who underwent 12 hours of general anesthesia. Godspeed sir, godspeed.
*** For the geeky among you, this is a cool link that chronicles the whole procedure with a series of pictures. (although they did an open abdomen)
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!
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!)
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.
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.
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.
