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.

Saturday, March 12, 2016

WILTIMS #451-3: Playing with toys

WednesdayIL: You can restart oral feeding on a patient recovering from esophageal surgery 7 days postoperatively, as long as there have been no complications.

ThursdayIL: A temporal artery biopsy is really not a big deal. We hear about this procedure all the time, because the disease it is diagnostic for, giant cell (or temporal) arteritis, is loved by test writers. And because a temporal artery biopsy sounds so serious, I always assumed it was a big difficult procedure. But after seeing a patient who had just had one of these biopsies, I now realize it's a super mild procedure. It required just local anesthetic and a tiny incision near the patient's temple. It takes all of 5 minutes and is basically an outpatient procedure.

FridayIL: I'm pretty good at playing with laparoscopic equipment. Today we met with our site director in the hospital's surgical skills lab to practice... surgical skills. We spent a good half hour just tying knots (it's harder than it sounds, ok?!). After that, we would normally have practiced suturing, but in a wonderful moment of irony, we couldn't find any suture needles in the surgery practice room. But as our preceptor is an accomplished laproscopic surgeon, we decided to fire up the laparoscopic trainer machines.

Laparoscopic surgery is when you use a camera and various small tools to do procedures through small incisions. The practice setups have all the same equipment, like a video monitor, camera, and two instruments that look a lot like those dinosaur head extended grabbers, only much much smaller and, ya know, no dinosaurs. And instead of a person's abdomen, there is a tarp with holes in it that you can place anything under. We were warned that most people find these instruments difficult to use at first because the screen makes you lose your depth perception. This is when I perked-up, since I have one bad eye and never had great depth perception!

Our first target was a set of blocks with holes in them that you could take on and off of plastic pegs. (see example on the right) The goal was to pick one up, transfer it to your other grasper, and then place it on another peg. Easy. Having mastered that, our preceptor set-up a new challenge: cutting a circle out of a piece of gauze. For this one, we replaced one grasper with a curved pair of scissors. Slightly more difficult, but we got the hang of it pretty quickly. (see my gauze and a bonus knot to the left) Lastly, we were set-up to tie some knots laparoscopically. Now this was tough. After a ton of awkward attempts, I managed to tie some sad looking knots.

Future challenges could include suturing a fake wound. Supposedly, many surgical residents can take ten minutes just to pick up the needle in the correct orientation. Challenge accepted... someday. I'm still generally turned off to surgery, but the laparoscopic stuff was pretty fun.

Tuesday, March 8, 2016

WILTIMS #449-450: Or not to surgery

At some point in the last week I learned: Surgery is not for me. As with all of my rotations, I tried to start with an open mind. There was a time during first-year anatomy that I seriously considered a career in surgery. It's cool to be good as something physical as well as cerebral and I was no slouch with a scalpel/clamp. Surgery also provides fairly instant gratification. One day the patient has a problem, you cut them, the next day the problem is fixed (most of the time, and ignoring any problems you caused). Simple.

However, there are so many reasons not to do surgery. The lifestyle is horrible, at least through training. Recent changes have limited resident shifts to 16 hours, but many see this as worse than the previous 30 hour limit because it is harder to see all of your required cases and you could be forced out of the hospital when an important emergent procedure There is a proud tradition of hostility up and down the hierarchy of surgeons. An OR is an understandably tense place, but sadly a lot of the tension is due to the surgeons (both attendings and residents), who have learned that efficiency and kindness are mutually exclusive. My current team is actually very nice, by surgery standards, but they're still surgeons and there's never enough space for my admittedly sizable ego amid a roomful of theirs.

All of that aside though, I just don't enjoy the job. I find surgery tedious. Once you get past the whoa-we're-cutting-a-person's-body thing, there is just too much standing in a room and poking around in a very cramped space. The biggest issue for me is the lack of patient interaction. The surgeon meets the patient beforehand and follows up with them afterward, but every other specialty in which I have trained has had more (conscious) patient care. I like talking with patients. All medical activities are stressful for most people and the one thing that has consistently made me thankful for getting to pursue a career in medicine is putting patients and families at ease. I can do that in surgery, and I have built a raport with every patient whose case I've observed. But that I'm looked at as a weirdo for spending so much time with the patients, just puts a bad taste in my mouth.

I'm sure my views will evolve more as the weeks progress and as I see other areas of surgery apart from the vascular team I'm on right now. But these are today's thoughts.

MondayIL: It generally takes the near occlusion of two of the three major splanchnic aortic vessels to cause symptomatic intestinal ischemia. I'll try to break that sentence down a bit: there are three main blood vessels that supply the small and large intestines. The areas supplied by these vessels overlap, but if two of them get clogged, the intestine loses blood flow and start to hurt. The upper two blood vessels (the celiac trunk and SMA) have such good connections downstream from their blocked trunks that research has showed similar results for opening both vessels or just the SMA.

TuesdayIL: An 80% occlusion of the carotid artery is generally considered the cut-off for corrective surgery in an asymptomatic patient. For a symptomatic patient the cutoff is usually 70%.

Sunday, March 6, 2016

WILTIMS #443-8: Surgery

So it begins. This rotation is always built up as the big beast of third year. The hours are the worst, the residents/attendings are some of the worst (I'm looking at you OBGYN), and the miniboard is essentially testing you on all of medicine again plus some stuff on managing surgical patients. Wednesday I got up at 3am, to leave the house by 4:15, to get to the hospital by 5:15, to collect the vital signs on all of the patients for the team by 6am, when we start rounds. From 7-8 today was M&M - not tasty candy, but the weekly Mortality and Morbidity conference. Here surgeons present mistakes that happened this week so that everyone can learn from them. 8-9 was a grand rounds presentation on aortic valve replacements. 9-10 was a lecture on pancreatitis and some case presentations.

At this point, one of my classmates and I realized that we were already exhausted and we'd be lucky if we got to go home in another 7 hours. Thursday, after a case went far longer than expected, I actually left at 7pm - nearly 14 hours after I sleepily stumbled into the hospital that morning. I can't complain though because a classmate left that night at 9pm.

Eight weeks. EIGHT WEEKS. Eight. Eight weeks. Oh, and one of those weeks is night shifts. Plus two weekend shifts.

Survival is the goal here.

MondayIL: Low blood pressure in pregnant woman? Tilt them a little onto their right side to relieve pressure from the vena cava.

Phrase of the day: "Not dead until warm and dead." If someone is brought in with severe hypothermia and no signs of life, you must warm the person before you can pronounce them dead. Once you warm them, there is a chance that their extremely suppressed vital signs may come back. If not, then they're actually dead.

TuesdayIL: Vascular surgeons can build you a new aorta inside your crappy one, so long as they reroute blood to all the arteries that normally branch off of the aorta. Do not think this is some Bionic Man stuff; this is the absolute last resort and will probably only buy you a few more years before something catastrophic happens. The diagram on the right was drawn by our chief resident to explain what the plan was to the whole team.

WednesdayIL: Since acute pancreatitis is a clinical diagnosis (i.e. there is no test or scan that needs to be done to officially diagnose it), there is actually no need to do a CT scan until around 72 hours after presentation. At that point, you can tell the difference between inflammation and necrosis which can help steer management of the condition.

ThursdayIL: If you are inserting a bypass from an artery in the groin all the way to an artery in the lower leg, you need to cut out a vein too. You attach the vein (upside down so that the vein valves don't stop the blood flow) to the lower end of the artificial graft tubing. This provides some "give" to what would otherwise be a very rigid connection as veins are much more compliant (stretchier) than both plastic and arteries.

FridayIL: As a general rule, if a person has big, soggy looking legs, it's a problem with the veins. If they have tiny atrophic legs, it's a problem with the arteries. This makes sense. If your veins can't drain the blood out of the legs, the blood pools. If the arteries can't get blood to the legs, they waste away.

from Wikipedia
YesterdayIL: The IVC filters that we insert into the vena cava to catch blood clots are (1) placed very quickly in a 5 minute procedure, (2) only capable of catching pretty large clots - about the size of your pinky fingernail, and relatedly (3) only meant to stop clots that would kill you, not catch 'em all.

Looking for more? Check-out my previous post wrapping up internal medicine.

Wednesday, March 2, 2016

WILTIMS #438-42 : Medicine wrap-up

Ugh. Eight weeks of medicine was exhausting. It both seemed like it took forever, and yet it wasn't nearly enough time to master everything for the mini-board (ya know, 'cause it's all of medicine). Good thing I will get a chance to catch my breath on my next rotation: surgery! Did I say catch my breath? I meant never sleep again! Ah well. Sorry for the super-crazy delayed catch-up post. I'd say that I will be returning to a more regular schedule, but... surgery.

TwoWeeksAgoIL: The common antibiotic bactrim increases the creatinine level (a common marker for kidney dysfunction) without damaging the kidneys. So don't panic about a patient's worsening renal status immediately after starting bactrim.

TwoThursdaysAgoIL: The wait time for liver transplants varies dramatically by region within the United States. In parts of the deep south, like Georgia, the wait time can be as little as a month and a half, but in New York or California, the same patient could be waiting seven to eight months.

A patient must have been ignorant to their alcohol problem to be approved for a liver transplant for alcohol-related liver failure. If they had already been warned about their drinking, and continued to drink anyways, then we can't trust them with a precious organ that they might voluntarily destroy again. Newly diagnosed alcoholics must go through a rigorous sobriety program to earn their new liver.

Quote of the Day: "To do the lobectomy, you essentially burn your way through the liver. I think of it as Sherman's march to the sea..."

TwoFridaysAgoIL: Pes anserinus bursitis is the painful irritation of the insertion of three upper leg muscles into the medial aspect of the tibia. The name "pes anserinus" literally translates from latin as "goose's foot" because of the shape of the three muscles joining looks like the toes (do birds have toes? [shrugs] somebody call a veterinarian!) of a goose.

TwoMondaysAgoIL: ...how to draw an ABG and, more importantly, how it feels as a patient to have an ABG drawn. My classmate and I decided to fill some downtime by stabbing each other!!! We had both drawn venous blood (which is the normal blood draw) and we had both seen ABGs (arterial blood gases) drawn, but neither of us had drawn ABGs before. Arterial blood draws are known to be substantially more painful than normal venous blood due to the beefier architecture of the vessels. We didn't want to practice this potentially painful technique on patients. So we borrowed some supplies and successively and successfully drew ABG samples from each other's forearms. It didn't hurt at all as it was being done, but then a steady deep ache set in afterward that stuck with me for a few hours. Not pleasant. I will never frivolously order that test.

TwoTuesdaysAgoIL: An idioventricular rhythm can look like a backwards Mobitz type II 2nd degree heart block. It amazes me sometimes that things like that don't sound like gibberish anymore. So, an idioventricular rhythm is a heart rhythm seen after heart surgery where the ventricles are beating on their own without the guidance of the atria. Totally opposite of the norm, the ventricles are actually beating faster than the atria. On EKG, this can look weird and result in the few "p-waves" from the atria creep closer and closer to the QRS complexes or the ventricles. In a Mobitz type II heart block, the p-waves progressively pull away from the QRS complexes.