Friday, December 30, 2016

WILTIMS #514-5: Let's call it a night

The past few "days" have actually been part of my week of night-call during this sub-I. So, instead of working from 7am to between 4:30 and 6pm, I come in at 5pm and leave at around 6am. Night shifts are typically pretty mellow. There is usually only a senior resident, an intern, and sometimes a sub-I like me, so the number of patients we each cover is roughly double that of weekday day-shifts. But, as most patients and attending physicians sleep through the night (there are exceptions to both), normally there isn't much to do but say "hi" to each patient and write an abbreviated note on each. If all's quiet(never say this word in a hospital) and your pager is set to one of the more obnoxious rings, then you might even be able to find a comfy chair and nod off for a few hours.

On my first night of the shift, this was not the case. We admitted six patients all while one of the patient's I was supposed to be watching overnight slowly but steadily spiralled into septic shock. It's telling as to how surprising this development was by the fact that I was the one to whom this patient was assigned. Very quickly, however, my senior resident took charge and the management of this patient turned into a full team effort. By morning, when no one had slept all night, we finally called in the PICU (pediatric intensive care unit) team to come take this patient to their unit.

Thankfully that was not a typical night and things mellowed out a bit on the subsequent nights.

Saturday: Tonight we had a nice little medical mystery walk into our ER. A 3-4 year old girl* was brought into the emergency department because, though she seemed perfectly healthy, some routine labs that her primary care doctor has ordered came back with some disturbing results. According to the results they brought in, she had severe pancytopenia (pan = all, cyto = cell, penia = too few, pancytopenia = having low counts in red blood cells, white blood cells, and platelets all at the same time). Pancytopenia is always scary in kids because it's almost always caused by only two things: aplastic anemia, which isn't great; or leukemia, which is worse. I was one of the two people in the room as we explained the possible prognoses to the family. But, thankfully, this kid had none of the above.

It turned out that the patient's mother had a habit of requesting a course of corticosteroids from their pediatrician every time the kid got a cold. "Her cough always sounds horrible and just never goes away unless she gets the steroids," the mom said. A short round of high-dose steroids is sometimes prescribed for a severe or stubborn asthma exacerbation, but the side-effects are significant so we try to avoid that when possible. One of the ways we use corticosteroids is to suppress the immune system, since often it is the immune system's over-response that causes most of the discomfort of being sick. At the same time, viruses can sometimes falsely lower the white blood cell count (and other counts to a lesser degree) by pulling cells out of the blood and into tissues. But, as IL on Saturday, if you use steroids while fighting off a virus, the two effects can compound and give results that would otherwise look like leukemia.

SundayIL: Differentiation syndrome is a rare, but not unheard of, complication to treatment for acute promyelocytic leukemia (APML). APML is caused by a type of precursor white blood cell that stalls during its maturation and builds up in huge numbers. There is a great, almost miraculous cure to this specific form of leukemia achieved by giving a drug that forces the aberrantly paused cell lines to continue on their way to becoming mature cells. The cancer just melts away. Rarely though, this sudden release of immune cells can cause a potentially severe bout of havoc similar to an allergic reaction, called differentiation syndrome.

*As usual, some or all details have been changed to preserve patient anonymity.

Tuesday, December 27, 2016

WILTIMS #512-3: Dosing, ordering, staging and grading

Thursday: Don't underdose pain meds in children. We have a tendency to look at kids as being small and feeble and are reticent to giving then the full dose of pain medications, even after adjusting the dose for their weight. But that's just silly! We wouldn't give them less antibiotics than recommended just because they're small and cute, so why would we make them suffer when it's perfectly safe to give them proper pain coverage? It happens all the time though, so we have to be vigilant and follow the evidence.

ThursdayIL: The enzyme asparaginase, which is used as an adjunct cancer therapy, can be produced both in E. coli, our typical enzyme-mass-producing organism of choice, and Erwinia chrysanthemi (recently renamed as Dickeya dadantii), a bacterium otherwise only known as an infectious agent to plants. If a patient is allergic to the E. coli variety, they get asparaginase-Erwinia.

Friday: It's frustrating not being able to put in orders as a sub-I. Of course, it makes sense legally and for patient safety. But as we are the pseudo-doctors in charge of our patients, when a nurse needs something for a patient, they page us, not the other residents who can actually write orders. So it ends up happening with frustrating frequency that we have a plan in place for some banal anticipated event that is delayed because I need to get an actual resident to switch away from whatever they are doing to open up my patient on the EMR (electronic medical record) to sign off on my orders. It seems like such a simple task, but since everyone else is usually taking care of sicker patients, my requests almost never take priority. Again, this is how it needs to be for many reasons, but that doesn't mean it's not frustrating.

FridayIL: The staging and grading of acute graft-vs-host disease (GVHD) is pretty complicated. Each involved organ system has four stages of involvement and then the grade is determined by either of two different systems that weigh the combinations of staging of each organ system. For example, both systems only allow for skin involvement in the lowest grade of the disease; even stage 1 involvement of the liver or gut automatically raises the grading. But if you have stage 4 involvement of any organ, then you are automatically grade 4.

I also learned a nice rule of thumb for pRBC (packed red blood cells) transfusion in severe iron deficiency anemia. You don't want to overload the heart and cause heart failure, so only transfuse at a rate less than or equal to the hemoglobin level (e.g. ≤4ml/kg/hr for a Hg of 4g/dL).

Saturday, December 24, 2016

WILTIMS #511: Enemy at the gates

Fever is a very scary thing in cancer kids. In normal kids, even though the technical cut-off for fever is 100.4°F (38.0°C), we aren't really all that concerned with an otherwise asymptomatic fever until it's consistently hovering a good deal higher than that (Reminder: please don't ignore your child's fever because of my silly blog; let your doctor make the call). But if you have no immune system, like kids receiving chemo or transplant meds, then your body has a really hard time producing the signals that lead to a fever. So, if one of these kids hits 100.4°, then it means that they are likely already quite ill, but not showing the typical signs yet. It's like if you're fighting a war and you have no more troops; just because you don't hear any gunfire, doesn't mean the enemy isn't advancing right to your door.

WednesdayIL: Though ECP does stand for emergency contraceptive pill (as I learned in my OB/GYN rotation), it quickly became apparent that that is not what the pediatric oncologist was talking about in regards to treating a young boy's graft-vs-host disease. In this case, it turns out, ECP stands for extracorporeal photopheresis, a method of essentially cleaning the patient's white blood cells. The idea is to remove some of the patient's blood, separate out the immune cells, and radiate them with UV light to make them invisible to the rest of the immune system before reinfusing them into the patient. This technique is used in patients with cutaneous T-cell lymphoma and some autoimmune diseases.

I also learned that you have to be careful with dosing methotrexate (a kind of chemotherapy) in patients in renal failure, with Down's syndrome, and patients who are "third-spacing." The first case is pretty simple; your kidneys filter out the toxic medicine after it circulates through the body. When the kidneys fail, the toxic stays around longer than usual and can do damage. With Down's patients, there is thought to be overexpression of some enzymes on the multiplied chromosome 21 that interfere with the drug metabolism resulting in higher levels of active drug in the blood stream.

The last one is a bit more complicated. "Third spacing" is when a patient is collecting unusual amounts of fluid outside of the two typical fluid "spaces" in the body (inside cells and in the blood stream). Instead the fluid pools in places like the abdominal cavity or the area around the lungs. But this fluid can still absorb chemicals like methotrexate, removing active drug from circulation, so the dosage required to get a typical effect is much higher. The problem is that we are usually also trying to eliminate this "third-spacing" so if you give large doses of the drug and then pull the unused drug back into the bloodstream from the extracellular spaces, then you've now overdosed the patient with medication they already had in their body.

Saturday, December 17, 2016

WILTIMS #510: A tale of two frequent fliers

On Tuesday, I got to meet two of the heme-onc floor's frequent fliers. Now in most areas of medicine, the term "frequent flier" has a starkly negative connotation. In the adult ER, it conjures images of alcoholics, drug users, and the mentally ill* and is usually accompanied with rolled eyes and a sigh. But in peds heme/onc, there are two prototypes, of which I got to meet one of each this week.

One is the "sickler", a kid with sickle cell anemia who is seen every few months with a new sickle cell crisis. These are very painful experiences that we can only do so much for. The main reasons the child is admitted to the hospital are so that we can monitor them as they receive high doses of our most powerful pain meds and to watch for any life threatening complications of the disease process.

But slowly, as these crises keep happening, these patients can become desensitized to the medications, requiring higher and higher doses and even becoming addicted. Meanwhile the team who used to be looked up to as a kind family trying to help, starts to be seen as an incompetent, rotating group of idiots who are refusing to treat their pain. At best, sicklers are quiet and patient as they suffer through their pain and our annoying bidaily questioning. At worst, they are bitter and uncooperative.† But they are all well-known to the entire hospital.

The second heme/onc frequent flier is the totally healthy cancer/transplant kid. Depending on the type of cancer, some kids need to come into the hospital to receive their treatment. Other kids had a bone marrow transplant to treat their cancer (and have practically no immune system now so as to stave off transplant rejection) and need to come in because they spiked a fever or had a positive growth on a surveillance culture. These kids are often totally 100% healthy but, because of our appropriately cautious guidelines to try to keep them that way, they sometimes get stuck in the hospital for a few days while we double check that they aren't getting sick.

We love these kids. They are adorable and energetic and just want to be outside of their boring rooms. They can often be found coloring at the nurses station or playing with toys in the hallway. Most kids in the hospital, even when they are starting to feel better, like to stay in their familiar room surrounded by family. Our hospital works very hard to make sure that a child's room is a safe space, where we won't do painful procedures, like lumbar punctures, if it can be avoided. But the frequent fliers know all the nurses and doctors and like to be roaming the halls and saying "hi" to everyone. I have never worked harder to prove that a kid didn't need to be on isolation precautions (and thus be confined to their room) than when one of these kids comes back in.

TuesdayIL: Rhodotorula mucilaginosa is a common environmental fungus that on rare occasions can grow in the blood of immunosuppressed patients.

*There is a good conversation to be had about how these medical demographic groups should not have a negative stigma associated to them. But, especially in the ER, the way our medical system is set up makes it very hard to find long-term placement and treatment for these groups, so they are usually just stabilized and sent home or back onto the street. The frustration with the system is the real negative influence here, but the patients are often treated as guilty by association.

†Note that these patients start falling into the same camp as the adult ER patients discussed above; patients who the system has failed and whom are at risk for the caregivers to misdirect their frustrations towards.

Friday, December 16, 2016

WILTIMS #508-509: Pediatric Heme/Onc

[Same old story: this post recounts days long past. I refuse to let this blog stay dead! "Once more unto the breach, dear friends, once more..."]

As hinted in my last post via my TodayILearned facts, the specific service I'm on for my pediatric sub-I is hematology, oncology, and transplant. This service is actually a lot of fun, with fantastic attending doctors, and dedicated nurse practitioners and nurses. But I was quickly reminded of the life and death realities of working in this field.

We recently had a teenager transferred to our service from general pediatrics. The kid came in with some vague symptoms that just weren't going away. All but cleared to go home, one last test, a bone scan, was done and to everyone's surprise it showed metastatic cancer. A biopsy was done which the medical staff knew was going to all but determine the kid's fate. Most childhood cancers are very treatable; some are not. It came back as Ewing's sarcoma which has a <10% survival rate. It was a sobering reminder that not all of our pediatric patients leave with happy endings.

ThursdayIL: Patients with suppressed immune systems (like cancer or transplant patients) must have their blood glucose carefully watched. Fungus loves high sugar levels and can thrive (and kill) if the immune system isn't there to fight it.

From: Nabil M. Elkassabany, M.D., et al. ; Green Plasma—Revisited.
Anesthesiology 2008;108(4):764-765.
Somewhat relatedly, if a patient has a bad reaction to a transfusion, the blood products may have been contaminated. But if the patient received several kinds of products, like red blood cells, plasma and platelets all at once, which is the most likely culprit? Units of platelets are far more likely to start growing bacteria or fungus for the simple reason that they don't need to be refrigerated.

Tangenting again, blood plasma is usually an orangish-yellow but occasionally a healthy person will donate green plasma. No, these are not Vulcans/Romulans in disguise; unusually high, but still completely safe, amounts of ceruloplasmin, a copper containing compound in blood, cause the color change.

FridayIL: The top four causes of death for pediatric patients with sickle cell disease are:
  1. Infection
  2. Splenic sequestration
  3. Acute chest syndrome
  4. Multi-organ failure
The vast majority of children with diagnosed sickle cell in the developed world will live well into adulthood. But these kids do often end up in the hospital once and awhile for pain management during sickle cell crises, and it's important for us to know which extreme tragic outcomes we must make sure don't happen on our watch.

Sunday, September 11, 2016

WILTIMS #505-7: Professional firsts and a pediatric homecoming

Continuing to catch up, this post is from about a week ago.

This was a very exciting week for me. For starters, it was the beginning of my infamous fourth-year sub-internship. This is a month during which I am treated like a somewhat inept first-year resident (they are also known as "interns," hence I am the sub-intern or "sub-I," for short). This mean I carry my own patients! I'm still supervised by a senior resident and all of my notes and orders must be co-signed before becoming official. But as far as the average patient is concerned, I am their doctor during their stay. This is a big step-up in responsibility and a terrifying reminder that I will be a real doctor in eight months.

I had a bunch of big firsts for my budding medical career, which are listed along with my learned factoids below. But the biggest first, was that this was the first time I've gotten to experience pediatrics since picking it as the specialty I'm planning to enter. In fact it has been nearly a year since my pediatrics clerkship at the very same hospital. For the past few months I had a nagging fear that I picked the wrong field and would only realize it on day-one of my sub-I rotation, two weeks before my residency application is due.

Turns out that that fear was totally unfounded. Even with the new level of responsibility and some emotionally difficult cases, this has easily been my happiest week of medical school so far. The residents were kind and inviting, most of the patients made me smile every time I entered their room, and I felt like I finally had moved past the busy-work to start actually helping real patients. I'm excited again to practice medicine and stoked that, through the chaos of third-year, I managed to find a field that I think will make me happy for a long time to come.

MondayILearned: Metronomic chemo = chemo given a lower more continuous doses to limit toxicity and tumor cell regrowth. Induction chemo = stage one of treatment that puts a patient into remission. Consolidation/adjuvant chemo = sometimes optional stage two of treatment that increases the odds that the cancer won't recur.

Monday 1st: I was assigned my first pager! This pinnacle of 1980s communication technology is the ball and chain around the ankle of every resident physician. It's weird to be excited to receive something you know you'll soon loath.

TuIL:  Make sure to keep patients NPO (no food by mouth) before an abdominal ultrasound, because food leads to gas and ultrasound doesn't penetrate gas well.

Also, it's very hard to get a young child to accurately describe the symptoms of paresthesias (pins and needles) and numbness. Kids don't have the experience and vocabulary to describe what their feeling and the questions we normally ask to get things rolling are rather cryptic ("If this feels like a ten, what number does this feel like?").

Tuesday 1sts: I received my first page on my nifty new (to me) pager! And far more significantly, I entered my first order. As a not-quite-doctor, all of my orders have to be signed off by an actual physician, but I now have access to the part of the awful electronic medical record software to put in orders to be followed by nursing.

WIL: Hemophagocytic lymphohistiocytosis (HLH) is a rare genetic disease where the immune system is over-reactive and starts to attack and eat the body's own cells.

Wednesday 1st: Due to a freak accident in patient assignments, a third-year med student wrote a patient note for my patient. This was the first time a subordinate med student has done work for me and I got to give him feedback. Not exactly the biggest milestone, but it sure felt weird at the time.

Saturday, September 10, 2016

WILTIMS #502-4: The long-lost neuro conclusion!

The blog is still not dead! To sum up what's been going on: the final few days of neuro got left by the wayside, I was studying to take some big tests, and then the past couple weeks have been some of the busiest of all my time in med school. But I'm on nights right now, and some of the important things I need to work on are too important to work on while sleep deprived. Thankfully, I have still been stockpiling things that I've learned every day I'm in the hospital, so I have plenty to share, if I ever get around to sharing it!

~~~Now, we travel back in time to June and my final third-year clerkship, neurology. ~~~

One of the more subtle skills I've learned (but by no means mastered) during med school is figuring out the meaning of the innumerable acronyms that are used in medicine in general and each sub-specialty in particular. Some, everyone knows (e.g. EKG, IV, PO). Others are only commonly used by a select subset of medical professionals and are gibberish to everyone else (e.g G4P2010 of AMA w/ PMH of ASCUS s/p D+C desiring TOLAC p/w PPROM)*

A Monday several months ago, I started my few days in the neuro rehab unit of the hospital. Right away I was presented with the acronym CO, which I had never seen in this context. Carbon monoxide? Colorado? Unfortunately I didn't ask what this meant until so late that it felt awkward (kind of like asking what someones name is again 10 minutes into a conversation with them). But I did ask... and then promptly forgot again. I still can't figure out what it means. But as I haven't been in the neuro rehab unit in months and may never be there again, it can probably fade away in my memory dump, like of all those OBGYN abbreviations.

MondayIL: Strict bed rest causes a 1-3% loss of muscle mass per day. That adds up really fast, which is why there is such a big emphasis on getting patients up into a chair and then walking as soon as possible.

TuesdayIL: It's important to distinguish between crossed and uncrossed diplopia (double vision). When you ask someone if they are seeing double, odds are they don't know if their eyes are crossed or pointing away from each other; it would look pretty similar from their perspective. But to figure out what the problem is, you have to know which eye is moving normally and which isn't. That can be sorted out by looking at directed eye movements but knowing if the eyes are crossing is a good first step.

WednesdayIL: Occupational therapy was created in World War I to help wounded soldiers "occupy" their time. It has since evolved into a therapeutic discipline to help rehabilitate people to do the activities they need to live and work in society.

*Translates to: A woman of advanced maternal age who has been pregnant 4 times resulting in 2 births, an abortion and the current pregnancy, who has a past medical history of atypical cells of undetermined significance and a dilatation and curettage procedure and desires a trial of labor after having previously had a cesarean section presents with preterm premature rupture of membranes.


Sunday, June 12, 2016

WILTIMS #500-501: Happy Un-anniversary! (Un-niversary?)

This is my 500th What I Learned Today In Med School post! Yay! Well... actually this is only my 372nd post, because of all of my lazy, multi-day catch-up posts (like this one).

Ok, but it's my 500th WILTIMS fact! Woohoo! Um... not quite. I've actually posted way more than 500 facts because some days are just too interesting (like Thursday).

How about it's the end of third year?! Now that's a reeeeal stretch. I have a week left of normal clerkship days then a shelf exam next Friday. And thanks to board exams and whatnot, fourth year really won't start for months.

If anything this is a perfect example of how, if you choose a career in medicine, the milestones along the way are very arbitrary. Right now on our campus, because the various academic calendars don't line up, there are two second-year classes and one third-year class, but no first- or fourth-years. Our newly-grads are now technically doctors, but they're not board certified to practice anything yet and won't be for years.

But this is the way it should be. There are lots of blurry lines as large teams of practitioners add and lose members. Everyone is always growing and moving on to new, but similar things. We are never done. In fact the end goal is just to keep learning, to keep practicing medicine.

ThursdayIL: If a significant neck injury requires it, fusing the base of the skull to the top of the spine (occiput to C1 fusion (or the far cooler sounding: atlanto-occipital assimilation)) will protect the spine but lock the patient's head at a certain angle and orientation. You've got to be very careful where you point the head during that surgery, or the patient will always be looking at the sky or their feet or sliiiiightly of the the left.

The three most common groups who get spinal cord injuries are:
1) 16-25 year old males who get into motor vehicle accidents
2) >65 year old people who fall
3) Gunshot wound victims from urban centers

FridayIL: The common fibular (aka peroneal) nerve is very bulky right around where it splits into the deep and superficial fibular nerves. Unfortunately this spit often happens right over the head of the fibula. If this area gets injured or inflamed it can pinch off that nerve causing pain, numbness and weakness. To alleviate the pressure, you cut the connective tissue along the nerves in both directions. But that knot at the bifurcation is still sitting on that bone. So what you can do is divide the nerve all the way up the leg. Since all the nerve fibers are running parallel, nothing is damaged. It's actually exactly like when your old headphones are a little too restrictive, so you pull the two wires further apart. No harm, no foul.


Thanks for reading! Here's to the next 500! Wait... that would put me most of the way through residency... hmmm...

Thursday, June 9, 2016

WILTIMS #499: A surgery revisited

Image from Kbik at English Wikipedia
Back in my surgery clerkship I spent an unusually long 3-weeks on the vascular surgery team. One of the bread-and-butter surgeries that the vascular folk do is create AV fistulas for patients starting chronic dialysis. An arteriovenous (AV) fistula is an artificial connection between an artery and vein, usually in the arm, that allows for the higher blood pressure of an artery to inflate a low-pressure vein. Dialysis machines require a high rate of blood extraction in order for the treatment time to be a brisk 3-4 hours instead of all day. That means you either need to pull from a very large, strong vein (requiring a surgical procedure to place an infection-prone catheter) or divert arterial pressures into smaller, weaker veins (if you pull too hard on small veins, they simply collapse).*

One of the potential problems of having an AV fistula placed is that, once you divert all that blood to the veins, it bypasses the lower arm and hand. If the hand doesn't get enough blood it can become painfully ischemic (starved of nutrients). This phenomenon is called "steal," as in the vein stealing the blood from the arteries that go to the hand. Steal is very easy to diagnose: pinch off the AV fistula and the hand will almost immediately feel better. Fixing it requires more work; you have to do a revision surgery ASAP.

YesterdayIL: When the hand/arm loses blood flow like that, it hurts, but why it hurts can be complicated. The tissue is essentially suffocating and it tells the hand/arm nerves to tell your brain to change something. When you return flow it usually gets better. But if the steal was too great, or left too long, or the nerves were already damaged from prior disease like diabetes, then the nerves themselves can suffocate. But nerves heal slowly, if they heal at all. This pain doesn't go away right after the blood flow is returned and may even be permanent.

Another nerve pain problem with AV fistulas can happen if a nerve is compressed by the anatomical changes from the surgery or post-op inflammation. This pain, however, should only affect whichever nerve is being pinch, not the whole limb.

*The reason you can't just use arteries is that they are complicated with nerves and muscles that give them thick walls and make them very painful to access. Veins are just thin stretchy tubes.

Tuesday, June 7, 2016

WILTIMS #498: O.o

TIL: Parinaud's syndrome is a weird collection of neurological eye exam findings usually caused by a tumor in the pineal or midbrain regions of the brain. The most prominent symptom is the inability to look up. The eyes can still move up, but the patient can't look up voluntarily. This can be demonstrated with a "doll's head test" where you have the patient relax looking straight ahead when you suddenly rotate their head forward. Another part of the brain controls this reflex, so the eyes will roll up in their sockets just like a doll's, before reverting. If one of the eyes is more affected than the other, then the patient may have double vision from one eye being stuck lower than the other.

Image from here
The next sign of Parinaud's has a fun name: pseudo-Argyll Robertson pupils. This is when the pupils are dilated (the black of the eyes is larger than normal) and they won't constrict when you point light at them. You can still make them constrict though if you use a trick. When you look way off in the distance, your pupils dilate a little; when you look at an object really close to your face (like your nose), the pupils constrict a bit. This reflex should be preserved in patients with Parinaud's syndrome. Again, if one eye is more affected than the other then the pupils may be different sizes at rest.
Then we have a whole bunch of related problems with moving the eyes in unison. These patients have a problem when you have them rapidly look at an object close or far away from them. Normally, you want both eyes to move in unison and stop at the precise spot to properly focus on an object. When that doesn't happen (e.g. one eye moves faster than the other, or overshoots the target, or stutters to the spot rather than moving smoothly), the patient will experience temporary double vision. Often these patients will have a particularly weird problem called convergence retraction nystagmus, where the eyes will retract into the socket when you have them look at their nose. This is because the ocular nerve is getting confused and instead of using some of the eye muscles to look in a direction, it contracts all of them. This pulls the eyes inward. See the GIF for an example!

Image from here
Lastly we have Collier's sign, marked by bilateral upper eyelid retraction. This makes the patient look a little "bug-eyed," but specifically results in an uneven amount of white above the irises. For an example, take a gander at this fantastically mustachioed man on the left. He has white visible above the irises of the eyes; for comparison, see that neither of the persons pictured above have white visible there. If patients with Collier's sign could look up (which they usually can't, as per exam finding #1, above) the eyelid would match the movement of the pupil and recede even further up.

Monday, June 6, 2016

WILTIMS #496-7: Ohhh myyy-a!

FridayIL: The only place in the body where an artery empties into a larger vessel is at the junction where the vertebral arteries become the larger basilar artery. To get an idea of how weird this is it would be like two branches of a tree growing into each other to form a single bigger branch.

The only purely visual manifestation of an increased intracranial pressure due to hydrocephalus (too much cerebrospinal fluid in the head) is an increase in the area of the blind spot that everyone has in their eyes. This normal blind spot is caused by retina having a hole in it where the optic nerve enters the eye. If you have too much fluid/pressure, this hole can stretch wider. This symptom would be great for speeding up diagnosis, but it's very hard to notice or test. Do you notice your blind spots now? Would you notice if they doubled in size? Probably not.

Monday: Today I switched over to the consult team. Much like my two elective rotations in pulmonology and nephrology, on this service, the patients' primary problems are not neurological, but the primary team wants us to take a look for some reason. Compared to my previous neuro teams, the patients in this group are far more diverse in presentation (and interesting, imho). Whereas on epilepsy all the patients were being worked up for some form of seizures, and on the stroke team we saw variations on stroke, consults could be anyone in the hospital with any vaguely neurological complaint. One guy was shot in a gunfight, another had a heart attack, one fell and broke her leg, and someone else had muscle breakdown after a likely overdose. Sometimes our team's involvement is extensive, other times it's very brief. The consult for the lady who fell and broke her leg simply asked if we thought anything neurological could explain the fall. We're pretty darn sure that this was blood pressure related, not neurological, so we write a note to that effect for the primary team, and we probably won't see that patient again on this admission.

An ommaya reservoir
MondayIL: {This fact is very boring; feel free to skip below.}You can differentiate between a sciatic nerve injury and sacral plexus/spinal nerve root injury by testing the gluteus medius muscle. The leg nerves and all the gluteal nerves come through the same roots and nerve plexus, but the superior gluteal nerve which innervates the gluteus medius muscle breaks off from the rest after the sacral plexus but before the consolidation of the sciatic nerve. So if a patient has leg weakness and has difficulty abducting the leg (lifting it to the side) the injury is likely proximal to the start of the sciatic nerve.

An ommaya reservoir is a port that gives you access to the cerebral spinal fluid within the brain. It can be used to remove fluid just like a lumbar puncture (aka spinal tap) or to administer chemotherapy for a brain tumor in or around the ventricles of the brain. Patients with one of these have a little plastic bubble on or under their scalp that connects with a tube to the space in the middle of their brain. Trippy.

For people with a congenital valgus leg deformity ("knock-knees"), having a knee replacement surgery can cause nerve injury. The peroneal nerve normally runs very close to the head of the fibula, but in valgus people, there is often more space between these structures. A knee replacement surgery will fix the angle of the leg and put normal pressure back on the nerve. But as the nerve in one of these patients isn't used to that pressure, it reacts like it's being pinched, causing numbness and/or weakness.

Thursday, June 2, 2016

WILTIMS #495: The Beatle-CT Connection

Today we had an optional lecture near the end of the day that was meant for the senior residents and was way, way over the heads of med students like myself. One classmate and I decided to go anyways (since we had to be in that room after the lecture anyway) and we ended up getting a little heart-to-heart time with a neuroradiologist. He told me a story that I could barely believe and knew I'd have to fact check before sharing with anyone. Turns out it was totally true!

TIL: Sir Godfrey Hounsfield, the Nobel Prize-winning inventor of the CT scanner, funded his first prototype with the EMI record company's profits from the Beatles. Here's a quote from this 2005 In Memorium post in the journal Radiology:
"EMI, at that time, were concerned principally with the manufacture of records and electronic components and had no experience of radiological equipment. The Beatles, who recorded under the EMI label provided the most significant financial input to the company. The Department of Health and Social Security (DHHS)—as it was then—was approached by Hounsfield and radiologists James Ambrose and Louis Kreel and with commendable foresight agreed to support, with EMI, the development of a head scanner. Hounsfield and a small team were installed in the radiological department of the Atkinson Morley’s Hospital in Wimbledon—a location chosen to avoid wide spread publicity in the development phase. The Consultant Radiologist, James Ambrose, provided clinical advice and conducted the first clinical trials on a prototype EMI head scanner (Mark I) in 1972. The first clinical image of a patient with a suspected brain lesion revealed the presence and location of a cystic tumour."

Wednesday, June 1, 2016

WILTIMS #494: Lies, LIES!

We had an interesting case today where a patient had certain symptoms but was probably lying about or at least embellishing his/her symptoms. The amazing part was that my attending called it after listening to me present the patient for about 30 seconds. I was shocked, because I had totally believed the patient and this doctor hadn't even seen him! What I had described as the patient's story just didn't make sense from a physiologic perspective. I tried to withhold judgement until the attending actually saw the patient. Once he did, it only took a few insider-knowledge tricks and almost immediately he had secretly exposed to the resident and I that the patient was lying.

One of the tell-tale signs was simply biological. People with a brain injury usually display slow eye movements. Normal people's eyes (and this patient's) dart around as they think. It's actually nearly impossible to smoothly move your eyes voluntarily if you aren't tracking an object. Try it! Keeping your head still, follow your own finger as you slowly point from left to right and back. Now try to do that same smooth eye movement without a finger to follow. It's really easy to see when someone else tries this in front of you, but you should still be able to feel that you're eyes are jerking across the path.

This other trick was not biological, but psychological. The patient answered several questions wrong, but always nearly right. If someone does this enough times it shows that they must know the right answer and are trying to be just the right amount of wrong. When people really don't know it's random and sometimes they're right, sometimes they're close, and sometimes they're totally wrong.

TIL: Vasculitides (autoimmune inflammatory diseases of blood vessels) that affect the brain are very often associated with headaches. But the brain has no pain sensation, so what is actually hurting? Well, while the fat and nerves of the brain itself don't feel pain, but the large blood vessels of the brain do and that's what is damaged in these diseases. Specifically, the arteries feel pain up to about an inch out from the Circle of Willis and the veins feel pain when they are of a similar size to the arteries, though the anatomic locations are harder to describe.

There are two modifiable predisposing factors for multiple sclerosis: smoking and vitamin D deficiency.


Tuesday, May 31, 2016

WILTIMS #493: Neurology - Inpatient

What's this?! A single-day blog post released on the day about which it's written?!?!?! Madness!!! Check out the previous three catch-up posts I finished today here, here, and here.

Today I started my holiday-shortened week of inpatient neurology. This mostly consists of stroke patients, which is, let's say... less than uplifting. This morning was spent walking room to room testing patients' neurological deficits while families looked on with either false hope or resigned acceptance. The deficits are usually the same as the day/week before and most of what was their loved one is now gone. The questions become: How much of the person is left? Would the patient be happy living like that? Where do they go from here?

It's sad, but this is very accurate.
TIL: With "locked-in syndrome," where the conscious mind is preserved within a paralysed body, voluntary vertical eye movement often returns and enables communication. It's easy enough to test; today we talked to/at a woman in a post-stroke vegetative state and told her to look up and down, or to look at the doctor's face that was out of her vision above her gaze. Her eyes simply continued sliding left and then whipping back right, like she was watching an eternal typewriter.

WILTIMS #488-92: Neurology - Epilepsy

This is the third catch-up post in the past couple hours. Make sure not to miss one! Here is Nephrology - Part I and Nephrology - Part II.

Last week I started my four week rotation in Neurology. This is my last rotation of third year! Woohoo! Each week of this rotation I am on a different team, starting with epilepsy on week 1.

Epilepsy is super boring. Well, epilepsy as a collection of disorders is actually really interesting, but treating epilepsy patients in the hospital is usually really boring because the patients are rarely actually seizing when you're standing there. Usually they had a seizure at home and were brought in to the hospital once they've stabilized. Then our job is to figure out if they truly had a seizure, why they had one if they did, and keep them from seizing again (usually by starting or raising the dose on the same cure-all anti-seizure meds).

A sample EEG with a seizure on the right half
The mainstay of epilepsy diagnosis is the electroencephalogram (EEG), which is always depressing. Either it will confirm a diagnosis of seizures, which is never fun, or it shows that there weren't any seizures while it was recording, which either means that the patient's problems are not caused by seizures, or that the EEG just got unlucky and there normally are seizures.

MIL: When doctors adjust the level of drainage for a ventriculostomy (tube that removes cerebral spinal fluid (the juice your brain floats in)), they counterintuitively talk about increasing the ventriculostomy to wean off of it. This is because the number that they are increasing is the amount of intracranial pressure (ICP) above which the ventriculostomy tube will start draining. A great analogy that a nurse shared was it was like raising the height of the overflow pipes from a dam; if you raise the height, the dam has to hold more water before it overflows. Lower numbers mean less stress on the dam/brain.

TuIL: Seizures on EEG look as if the squiggly lines have increased in every way: frequency (they're more common), amplitude (they're taller), and rhythmicity (they have a consistent pattern).

WIL: Shivering suppression can hide seizures in patients being treated with therapeutic hypothermia after a cardiac arrest. A common treatment used after the heart stops for a prolonged time is to lower the body temperature. But this can cause violent shivering as the body tries to maintain homeostasis. The drugs used to stop the shivering are paralytics that prevent the muscles from contracting. This works great, but if the patient is having seizures (as ~30% will, post-cardiac arrest) then the paralytics will stop you from discovering the seizures. Even though the patient isn't able to twitch or spasm, the brain might still be being damaged by the silent seizures.

ThIL: There are four broad kinds of sedating drugs: benzodiazepines (like versed), opioids (like fentanyl), alpha-2 adrenergic agonists (like precedex), and propofol (which is in a class of its own as we don't even understand its mechanism).

FIL: Nemaline myopathy is an atypical muscular dystrophy that results in weakness in skeletal muscles, typically most severely affecting the face, neck and limbs.

WILTIMS #483-7: Nephrology - Part II

This is part II of my rapid-fire catch-up series. Click here to read "Nephrology - Part I" which was posted only an hour before this post.

One of the things that I find endearing about nephrology is that when you work in a hospital, you already know most of your inpatients very well. That's because one of the biggest predisposing factors for acute kidney injury is chronic kidney injury. Dialysis patients are always a knife's edge (or 2-3 days without a dialysis treatment) away from the emergency room. If your kidneys are totally non-functional then you need dialysis at least 3 days a week. If you miss an appointment, the toxins that the kidneys (or dialysis machine) should filter from the blood can cause all manner of dangerous side effects very quickly. When these patients show up in the ER, though, it's not like a typical consult for the nephrology doctor. You've seen these patients 3 times a week for months, years, or even decades.

My final thoughts on nephrology are similar to my thoughts on pulmonology: working with just one organ system is incredibly frustrating. In pulmonology, we often started reading up on a patient not by reading the history and physical, but by looking for a chest x-ray or CT scan. All we cared about was the lungs. We once had a family ask about the patient's brain tumors and we honestly didn't know they were being treated for that; all we cared about was their pneumonia. In nephrology, we were very big on the blood tests. If a patient we'd followed for several days didn't have blood work ordered by the primary team, we might not even bother seeing the patient that day.

I don't want to work in a field that can clear a patient "from the [insert organ here] perspective." How is the patient? Well she's fine from a kidney perspective (but I think I saw a note that her leg needs to be amputated and the septic blood infection from her UTI is life-threatening). I'd much rather be in charge of the whole picture and ask other colleagues to comment on their particular organs. But that's just me.

MIL: If a patient has any amputation due to diabetes, they have a 48% chance of having another amputation within 3 years.1

TuIL: If you google the acronym "MMF," the definition offered by urban dictionary is not medical meaning of mycophenolate mofetil, a immunosuppressant enzyme inhibitor used to prevent transplant rejection.

WIL: The maximum renal clearance in a healthy young adult male is estimated at 180 liters per day.

ThIL: Dialysis disequilibrium syndrome is an increasingly rare reaction to the abrupt change in blood contents after a patient first has a dialysis session. It's normally seen hours after the dialysis session starts, once the blood is mostly clean.

from http://kidneystones.uchicago.edu/
"Dialysis reaction" is a reaction of the blood to the membrane used in older model dialysis filters. Compared to disequilibrium reactions above, these dialysis reactions happen almost immediately after beginning the dialysis session.

FIL: Medullary sponge kidney is a congenital disease of the kidneys where the kidneys look like - you guessed it! - sponges. These porous, cystically dilated kidneys usually cause very few, if any, symptoms. The only problem that sometimes arises around middle-age is that the kidneys repeatedly form large stones that can cause obstruction of the ureter and damage the kidney. If it's not caught quickly, the affected kidney can fail entirely and, given the mildly debilitated other kidney, cause the patient to need periodic dialysis.

WILTIMS #479-82: Nephrology - Part I

Sorry for falling behind again! I have been taking notes in my little black book (spoiler-free example page on the right), and I'm hoping to do a crazy series of catch-up posts over the next day or so.

A few weeks ago week I started my second two-week elective, nephrology. Taking a detour south from the lungs, I turned my currently myopic gaze to the kidneys. One of the reasons that nephrology was on my elective list was that kidney pathology is very physiology-heavy. You have to really know how the organ functions on a biochemical level to diagnose and treat kidney diseases. I like this connection with the basic sciences and the similar reliance on physiology in intensive care is part of why I'm leaning that way career-wise.

MIL: Dialysis machines measure the sodium concentration indirectly by measuring the conductivity of the dialysis solution. Pure water conducts electricity poorly, while salty water conducts very well. By measuring how conductive the water is, you can determine how salty the water must be. The predominant cation (positively charged molecule) in the dialysate broth is sodium, so conductivity ≈ saltiness ≈ sodium concentration. Who says high school chemistry was never useful!?

TuIL: Acute kidney injury (AKI) is classified by several systems. The older model is based around the RIFLE acronym,

WIL: Wednesday was our last class meeting of the year. We finally learned how we are going to sign up for our various fourth-year courses! Kind of... We subsequently had a lottery for our required courses and are still waiting for open enrollment for our electives. I also learned that there are over 20 people in my class planning on going into pediatrics, which is a huge increase over previous years. This made our required fourth-year course work difficult to schedule, because the simply aren't enough spots for everyone to do everything at convenient times.

ThIL: ACE inhibitor drugs decrease the filtration rate of the kidneys in the short-term. This is generally a bad thing for an already stressed kidney. But, in the long-term, the decrease in blood flow decreases the rate of glomerular damage. Think of it like an old car that is always parked under a bird-filled, pollen-generating tree. If you wash it every day, it gets clean, but eventually the paint is going to wear off. So wash it less often; that way it still gets cleaned regularly but, in the long-term, you avoid damaging your paint job.

Sunitinib is a chemo drug that has a side effect of dramatically increasing blood pressure. The effect is so consistent that blood pressure is often used as a marker for how well the chemo is working.

Many drugs break down in the body into active and inactive metabolites. If a patient has severe kidney disease, though, the inactive metabolites can build up to such high levels that they actually start causing side effects. Enough of anything is poisonous.

Thursday, May 12, 2016

WILTIMS #474-8: Pulm Week 2

After finishing my first elective in a medicine subspecialty, I'm pretty sure I never want to specialize in any one organ. Doing just lungs or just anything everyday seems really monotonous to me.

My other takeaway is that, while surgeons often ignore patients on purpose, medical doctors can still ignore patients accidentally. One of my attendings this week had a habit of thinking out loud to the rest of the team while standing over the patient - not a bad thing necessarily. But then he would occasionally keep thinking out loud and just wander out of the room without ever summarizing or saying goodbye to the patient. I started to lag behind to quickly translate to the patient what I thought was going on. To my classmates: please don't pick up this habit. It makes otherwise kind and considerate doctors seem like assholes.

MIL: Sickle cell disease can increase reticulocyte (immature red blood cell) levels which can be mistaken for white blood cells (WBCs). Leukocytosis (high levels of WBCs) indicates inflammation, usually caused by infection, so these patients can be needlessly worked-up or treated for an infection they don't have, if you don't think about this common lab test error.

TuIL: A cheap treatment for sleep apnea is having the patient wear a shirt with a breast pocket backwards and put a tennis ball in the pocket. This way, the patient can't lie flat on their back, which is one of the ways to stop the airway from collapsing in sleep apnea.

WIL: The PaO2/FiO2 ratio is the ratio of the pressure pf oxygen in the arteries to the oxygen content of the inspired air. It is a simple way to estimate lung function and used to categorize the level of adult respiratory distress syndrome (ARDS).

ThIL: Telephone standardized patient encounters are weird but not as scary as people tend to think. Most of our practice patient encounters are in person, talking to and examining an actor. But part of our board exam that I take this summer includes telephone interactions, where you enter an examination room and call an actor in another room. Usually this is one of the ways that they test students' proficiency in patient care related to pediatrics, as having child actors would be problematic.

FIL: Extracorporeal membrane oxygenation (ECMO) is an attempt to make for the lungs what dialysis is for the kidneys. It is essentially a less-than-fantastic artificial lung that is sometimes used in ICUs when a patient's heart and lungs aren't doing a good enough job at oxygenating blood.

Friday, May 6, 2016

WILTIMS #469-73: The Great Restart

Last week I started a quick two-week rotation in pulmonology, the study and treatment of lung and other respiratory disorders. I had particular interest in this elective because, as I've mentioned before, I'm thinking about someday practicing as an intensive care doctor. Though I'm leaning toward pediatric critical care at the moment, if I should choose the adult route, many adult critical care doctors are actually double trained in pulmonology and critical care (or "pulm-crit" for short). This is historically due to the close correlation of lung problems with critically ill patients; many ICU patients are on ventilators that breath for them while they're in the unit.

Monday: On my first day with the pulmonology consult team, some cosmic karma balance was achieved as I had the privilege of apologizing for the terrible communication and bedside manner from a surgery team. They apparently cancelled a surgery after the patient was already under general anesthesia for a complication that could have been easily foreseen days before. Then they didn't tell the patient or family what happened or what the next steps were. It just takes a little communication, folks!

MondayIL: Ground glass opacities on CT scan can be misleading. This term means that the there are areas of light and dark patches making up the lung tissue. The question is: which is the healthy tissue and which is diseased? By tinkering with the image settings you can make the light or dark look normal, so radiologists have to use special tools to compare the lung tissue with known brightnesses in the image, letting us know which it is. We can also make educated guesses based on the condition(s) we're suspecting.

TuIL: What a bronchoscopy procedure looks like. I had heard about this sort of colonoscopy of the lungs, but hadn't seen one performed yet. Having seen many colonoscopies and endoscopies while volunteering before med school, the process is very similar. The only catch, of course, is that instead of exploring a solitary tube, you are exploring an incredibly complicated tree. Also, with the GI tract, you can inflate it with air to help you see, but the lung pipes are not nearly as expandable, so you run out of room and visibility very quickly. Want to rinse something with water? No problem in the bowel but, in the lungs, you are literally drowning the patient so you have to suction the fluid back out immediately.

WIL: There is a super rare condition called Erdheim-Chester disease that has only been reported in less than 500 individuals. Odds are the patient we are consulting on is the only one with this disease I will ever see in my career. It has many diverse manifestations, but for my pulm team, we are most concerned with the devastating cystic lung dysfunction that is seen in these patients. Unlike in emphysema, where the tiny bubbles of the lung stretch outward like bubble gum blown too big, cysts have thick capsules that keep them from popping. When your whole lung slowly turns to these thick balloons of useless tissue, it makes breathing rather difficult.

Thursday: This was a weird morning because we waded into an ethical quagmire due to some dubiously informed consent. We wanted to try 'scoping a man who the anesthesiologist considered a very high risk patient. The problem was that the patient didn't seem to grasp that there was a small, but non-zero risk of needing to be intubated (put on a breathing tube) if his vital signs deteriorated. He wanted the procedure, but not the risk and you can't have it both ways.

We tried calling his family, but they were similarly indecisive. Meanwhile, Anesthesia recruited two more of their own to consult as to the risk to this patient. Our team was four people on its own. Nursing had at least two people in the conversation. For patient privacy reasons, we moved the mob to the still empty procedure room. After going back and forth about the risks and options for different levels of anesthesia and trying to justify why we were doing this case at all, it was decided to call the patient's primary doctor for this admission, the head of cardiac transplant surgery, who decided to join us for the discussion.

The man swaggered into the suite and basically dismissed everyone's concerns about both patient safety and consent. "The guy's heart is failing; of course it's risky. So is anything on this guy." He then wandered over to the patient's bedside and asked, "You want the procedure, right? Good. Let's just get this done." So we did. The patient got very limited sedation (because anesthesia wasn't comfortable giving him anything that might jeopardize his cardiac function) and was coughing and gagging the entire time we had a tube down his throat. We got our samples. The patient didn't remember a moment of the half-hour I was restraining his hand from pulling out the tube in his lungs. He woke back up with no ill effects.

I still don't think we should have done the procedure. The patient consented wholeheartedly by the time we went (even though he still didn't want a breathing tube), but he explicitly said that it was because he wanted to eat after a whole night of being NPO (nothing by mouth). There was a lot of gray area in every aspect of this event and, if the patient's life is not on the line, it probably makes sense to take a step back and reschedule the procedure for the next day, once we can be more clear about the risks and the patient's understanding thereof.

ThIL: Jugular venous distension is a very specific physical exam finding but not very sensitive, because the anatomical distances we use are severely underestimated.

FIL: Tree-in-bud opacities are a radiographic finding on CT imaging that looks... like a budding tree. It can represent many different pathologies, but generally means there is something filling up the deepest airways of the lungs.
From: http://pubs.rsna.org/doi/full/10.1148/rg.253045115

Sunday, May 1, 2016

Surgery Post-Mortem

[beep]...
"Wait, is that a...?"
[beep]...
"We've got a pulse!"
"I thought we lost it in surgery!"
"We did, but it's back. Let's make the most of it!"
I'm not dead! And neither is my blog, though neither of us made it through that surgery clerkship unscathed. For the first time in nearly three years, I will not be logging something I learned for each day of medical school. Between the night shifts, the already miserable day shifts, and studying for the shelf-exam, I just couldn't spare the time or, more importantly, the energy to write my blog on top of it. So I will give you my parting thoughts on surgery and then start clean with the pulmonology elective I started on Monday.

I loathed my surgery rotation, but I did not loath surgery itself. It's very satisfying to be able to definitively do something for a patient other than think, tweak, and wait - as is the norm in most of medicine. Your appendix hurts? Cut it out. Your gallbladder is inflamed? Cut it out. Your stomach holds more food than you'd like? Cut part of it out. Your leg is trying to kill you? Cut it off. Yes, surgery creates scars but, in a way, those are marks of where we tried to help.

I also liked the tight-knit team atmosphere. In order for a surgery to happen efficiently you need the collaboration of the surgeons, med student*, anesthesiologist, scrub tech, and circulating nurse - plus the countless other people who are tangentially involved, like the pre-op nurse, PACU nurse, whoever the people are that clean the stretchers, the laboratory for rapidly interpreting intraoperative specimens, and others. When everyone is working together like a well oiled machine (preferably to the groovy tunes of the Beatles (it happened once!)), it makes me proud to be an (optional) member of the team.

*You don't actually need a med student unless there is some part of the body that needs retracting that there isn't already a good retracting device for (e.g. the liver can typically be retracted by a adjustable metal arm attached to the bed) or if you're lazy and want someone to help** the resident suture at the end.

**Note: this may not actually speed things up.

But even at the hospital I rotated at, noted by past students for being pretty mellow compared to other hospitals, the professional environment was often toxic. Attendings belittled the senior resident who belittled the residents and interns who belittled us. Everyone is overworked and sleep deprived, but to show either is to show weakness.

This field is also the only one I've experienced all year where a resident or attending asks what you want to do for a living and is annoyed when it's not their field. Tell a psychiatrist that you don't want to do psychiatry and they respond, "Ah well, few do! But let's see if we can give you the basic knowledge that will help you in whatever field you do choose." Surgeons tended to want us to learn what they had to learn: names and techniques only very tangentially applicable to anyone shunning the surgical specialties.

My least favorite part of the rotation was that I was so miserable that I was at times a grumpy asshole to the few residents who actually were nice me and to my classmates who were just as tired as I was. They say you get used to the schedule and pace of surgery, but honestly I worry about the version of me that would come out the other side.

Thursday, March 31, 2016

WILTIMS #467-8: ♪♫ Sol do la fa mi do re! ♫♪

Wednesday afternoon, I got to assist with my first thyroidectomy, where we remove the entire thyroid gland from the neck. These procedures are dreaded by most med students because they take forever, usually about 4-5 hours. Often, four people are all crowding around a small, deep incision in the patient's neck, which means lots of retracting at awkward angles and in awkward stances. The work is all very meticulous because the structures of the neck are all so close together. If you're not careful, you might cut a nerve (causing voice hoarseness), perforate the trachea, pierce the jugular veins or carotid arteries, or remove one or more tiny parathyroid gland along with the thyroid.


Image from here
YesterdayIL: Giant paraesophageal hernias are called "giant" because the term groups together the two largest classifications of hiatal hernias (III and IV). Paraesophageal hiatal hernias are when the stomach/esophagus junction stays in place (unlike in the more common sliding hiatal hernia), but another portion of the stomach actually squeezes through the gap into the chest cavity. Giant paraesophageal hernias are actually quite dangerous because they are usually relatively asymptomatic unless the stomach gets completely pinched off, forming what's called a gastric volvulus. This is a surgical emergency and has a very high mortality rate without prompt treatment (>50%).

When surgically repairing the hernia, if the stomach appears viable, you must secure it in the abdominal cavity. To do this, you need to attach, either with sutures or gastric tubes, in at least two locations to prevent the stomach from twisting around a single point of attachment and becoming ischemic (not getting blood/nutrients).

TIL: When doing a post-operative check on a thyroidectomy patient, ask the person to mimic you at various vocal tasks like a singer (e.g. "Repeat after me, 'La la la!' 'Sol sol sol!' 'Mi mi mi!'")

Tuesday, March 29, 2016

WILTIMS #464-6: BFFs and robots

Saturday: I was a patient's BFF! And she said it during morning rounds with the chief!!! Let's go back to Friday for a second.

(Friday:) There was a patient I was following because I had been in her surgery earlier in the week. She was having a real hard time with her recovery, in part due to not being able to get up out of bed. We wanted her to walk and sit in a chair, but the combination of pain, dizziness, nervousness, and her somewhat intimidating size made it so that no one felt comfortable helping her, for fear that she might fall (a BIG no-no in hospitals).Well after two days of nursing and physical therapy not getting her out of bed (heaven forbid the doctors actually try), I decided to make it happen. I grabbed a couple of med students and we slowly, patiently, helped the patient out of bed to a nearby chair.

It was a pain for everyone involved and took a good 10 minutes (10 minutes!? My god! No one has that kind of time!), but we managed to get her to the chair. And she was so grateful she cried. It's ridiculous to me that it was this much of an ordeal to accomplish this little task.

The next morning for our smaller weekend morning rounds, the chief resident, an intern (1st year resident) and myself walk into her room and the patient says hi to everyone, but specifically smiles at me and says, "Hello, Christopher."

At this point the two doctors stop and look over to me quizzically. "You know his name?" the intern asks.

The robot.
"Oh yes. Christopher was the man yesterday. He and some friends helped me to the chair when no one else could. Christopher said he would get it done, and he did."

"So, you guys are BFFs now?" the intern facetiously asks. "I'm starting to feel jealous."

"Yep. We're BFFs."

I am eight shades of red at this point, but feeling pretty darn good. I might make a mediocre surgeon, but I take good care of my patients.

SaturdayIL: Normally, retracting or manipulating a body part is pretty simple, but a soapy scrotum is very hard to hold in a specific orientation.

The video game control console.
Monday: Yesterday I got to see my first robotically assisted cases. The first was simple and the second was a disaster, but not because of the robot. The robot is really cool and creepy looking (see on the right). The robot essentially allows you do a laparoscopic surgery, but in 3D, with super-human precision, and using tools with intuitive wrists. There are also four arms on this model, so you can retract things for yourself or have a second person control those from a second console. When the other console isn't in use, the med student gets to watch the surgery in 3D too!

The doctor using all this technology tried to justify it's use by saying that traditional laparoscopy has reached a limit as to what it can be used for. This robot-tech is better, but we haven't figured out the best uses for it yet (outcomes for robotic procedures vs. current laparoscopic surgeries are identical (but far more expensive)). I'm not convinced, but if cost weren't an issue, I could see the appeal of robot help.

MondayIL: Holding pressure on a perforated splenic artery during a robotic-assisted surgery is fairly complicated.

TuesdayIL: Bariatric surgery patients often develop acid reflux after the procedure because their newly shrunken stomachs simply can't hold that much acid anymore and it backs up into the esophagus.

Friday, March 25, 2016

WILTIMS #462-3: Prism definitions

ThursdayIL: You can develop acalculous cholecystitis (inflammation of the gallbladder NOT due to stones) just from not eating. If your body is producing the same amount of bile to help digest food, but you aren't eating anything to stimulate its release, then the storage container of the gallbladder can get distended and irritated.

Percutaneous transhepatic cholecystostomy (PTC) is the placing of a tube into the common bile duct through the liver via the skin.

Hypotonic biliary dyskinesia (poor movement of the gallbladder due to low muscle tone), aka having a "lazy gallbladder," can cause all the symptoms of a gallbladder problem with none of the diagnostic findings. To diagnose it, have a HIDA scan done (test that injects dye into the bile duct to visualize the whole biliary tree) and then give CCK (hormone that stimulated gallbladder contraction). If the gallbladder's ejection fraction is less than 40%, you've found your problem. The solution, which is almost always the answer with gallbladders, is to cut it out.

TodayIL: There are pros and cons for reversing a vein versus leaving it in the same orientation but destroying the valves when using it as a graft for vascular bypass procedures. We were taught back in anatomy that when they use veins as arterial grafts, that they reverse the direction of the vein, because veins, unlike arteries, have valves that would stop the flow if the vein isn't turned upside down when fitted to the artery. However, there is a downside to this procedure; all vessels get smaller as you move away from the heart. That means that, when reversing a vein to act as a graft, the small end has to be attached to the big, higher flow end of the artery and the big part of the vein is wasted on the small end of the artery. Because of this problem, there is another option: you can break the valves. The downside to this is that the device that physically damages the valve structures might also damage the vein.

Read Wednesday's post here!

Wednesday, March 23, 2016

WILTIMS #459-461: Riddikulus!

MondayIL: Restrictive bariatric surgeries (when you decrease the size of the stomach to prevent a person from eating large meals) is not super useful for patients who are "grazers." These people tend to just constantly eat small amounts of food throughout the day, which adds up to enormous caloric totals. Restricting the stomach's size wouldn't do much to prevent these people from continuing with the same detrimental lifestyle. In contrast, "bingers" mostly eat at normal meal times but eat monstrous proportions. These are the best candidates for restrictive bariatric surgeries, as they will feel sated after eating only a tiny proportion of their normal portions.

Tuesday: Yesterday was fairly action packed. I saw three procedures: a hernia repair, a lymph node biopsy, and another far more complicated hernia repair. The team I worked with was surprisingly pleasant for surgeons. I got a good amount of medical student tasks (retracting, applying suction, cutting suture threads, and a little bit of suturing), but the most fun was actually a trip to the pathology with the lymph node of our second patient. There I watched a moment from my past from a different perspective.

The node in question was greatly enlarged and even upon the first incision into the tissue, the pathologist said it looked like lymphoma. Using a surprisingly wonton dying process, the pathologist prepared a thin slice of the tissue to look at under the microscope. This was a teaching microscope with two heads, so I could look too. There the pathologist pointed out the different cell types and said that preliminarily he would give a diagnosis of lymphoma, likely of the Hodgkin's variety - the same one I was diagnosed with 4 years ago.

YesterdayIL: A panniculectomy is the surgical excision of the excess folds of tissue below the belly that can occur in the very obese. We performed a pro bono one of these yesterday since we needed to get below that tissue anyway to repair the patient's hernia. I had the unenviable job of holding back the ~10 pounds of fat as two surgeons cut it away from the tissue beneath. It was quite a workout.

TIL: ...how to do a continuous subcuticular stitch. I've seen pieces of this technique several times but today I got to practice from start to finish on a patch of fake skin in the surgical skills lab with our preceptor. Now, if only I could practice with fake blood and a surgeon-boggart to replicate the OR anxiety...

Monday, March 21, 2016

WILTIMS #454-8: Big cuts, disappearing veins, and confirmed aspirations

Last week was a long one, and so is this post. Yay?

MondayILearned: Holding someone else's arm in tension is exhausting for more than 5 minutes. Also, a rib extraction through the axilla is pretty underwhelming when the rib is taken out in little pea-sized pieces. Also also, if you are holding/pulling someone's arm as long/hard as you can, you don't get a great view of the armpit through which they are doing a rib extraction.

Tuesday: I cut off a person's leg! Well, the attending cut some, and the resident sawed the bone but I used the scalpel to cut through the last couple inches of the patient's thigh to sever it from the body. That was surreal.

TuIL: When amputating a limb, it's a pretty quick and dirty affair up to and immediately after the main blood vessels have been closed up. You pick the line you are going to cut down and make deep clean cuts through the skin, fat, and muscle, but slow down when you know you're near a main artery or vein. These you clamp well before cutting or else risk considerable blood loss. Get down around the bone, clean off the tissue and whip out your handy-dandy electric bone saw. Make sure your med student is holding the distal limb as it is about to no longer be supported by the skeleton. Then keep on cutting. Angle out toward the dead limb near the end to create a flap of tissue with which to create your stump.

Wednesday: After the usual morning lectures, including a particularly schadenfreudenous M&M (morbidity and mortality), I spent the afternoon in the vascular surgery clinic. It was a little awkward because the resident I was shadowing for the day was essentially shadowing the attending, who happened to be the chairman of surgery for the whole hospital. Honestly though, I probably wasn't any more useless than I normally am in the OR.

Lovingly borrowed from UpToDate
WIL: Varicose veins can be removed instantly (it really looks like magic (needle-y magic?)) by injecting foamy soap into the veins which collapses and scars them closed. To make the foam, you use a funky looking right-angle connector pictured on the right.

Thursday: Instead of the normal OR, I spent this morning in the Cath Lab. This is the collection of specialized, minimally invasive procedure rooms where vascular procedures are done, like angioplasties (using a balloon to widen a constricted artery) or stent placements (expanding a mesh cylinder to keep the arteries open after the balloon is removed). These procedures can be done on the vessels of the heart, brain, or anywhere else all through a tiny tube inserted in the arm, leg, or neck.

ThIL: The cath lab has huge computer monitors to watch all the images taken by the doctors as they x-ray their way through the patient's vasculature. I'm not all that sad to see my vascular days behind me, but the added radiation doses I was getting from all these angiography procedures is an especially welcome loss.

Friday: This was my favorite day of the rotation so far (and it had little to do with surgery, unsurprisingly). As it was Match Day for the fourth year medical students who normally man the surgical intensive care unit (SICU), another third year and I decided to skip out on our normal teams (with their permission, of course) to help out the SICU team.

For some time now, I've been thinking that intensive care is the type of medicine I want to practice. But through this third year, as we are supposed to be learning about the different fields and making a decision, I've been hesitant to say that I want to be an intensivist because... well, how do I know? It's not like we are given much ICU exposure before 4th year. Every time I try to explain why I want to pursue this career, I feel like I'm just making things up that I've heard third hand or extrapolated from my limited pre-med school exposure to ICUs.

Today was great because I got to ask an ICU attending to pitch everything he loved about his profession to me. And every point he made confirmed points that I had been hoping to myself were true. The cerebral nature, bedside medicine, fun technology, teamwork, the best nurses, a focus on teaching... I'm sold. I also learned a new analogy for intensive care. Intensivists are to other doctors like relief pitchers are to starters in baseball; the primary physician takes their best shot at taking care of the patient on their own, but sometimes you need to bring in someone who specializes in getting out of a jam. It's not about wins, it's about saves.

Now, the bigger question: kids or adults?

FIL: There has been a big push in recent years in intensive care to get patients out of bed and moving around as soon as it is safe to do so. This is a big departure from the traditional strategy of strict bed-rest. The old idea was to conserve the patient's energy for healing, but the body doesn't work that way.