Good intentions...

So much for my attempt to keep everyone informed about my clinical experiences!! Things got SO SO busy with the ER rotation. I was working all sorts of crazy hours and trying to study for a ridiculously difficult test. I had no time for anything!!

Family Practice! Much, much better! I was starting to wonder if I had gone into the wrong career, because I was not loving my time in surgery. Thank goodness I am loving Family Practice - there is something about medicine I really do love. I actually get to talk to patients!! (ER was really fun as well, just busy). I have met some great people and have been able to see a lot of different things. I love it so far.

I am, however, realizing that some people take their health about as serious as I have taken to updating this blog - not at all! Some people just expect other people to do the work for them. (I'm glad Leisy keeps up the blog so well!) Some people just want Dr.s to fix them, but aren't willing to actually do anything about it; they don't want to take their medications, don't want to monitor sugar levels or BP, and forget about diet and exercise!! Just fix me doctor!!

Long, long week

My long week was topped off with a Sat to Sun 24-hour call. I accumulated 84.5 hours this week - it's amazing they make us pay tuition to work this much!

While I was on call I was able to work with a resident who was covering surgery from multiple services. This means I got to see surgical issues outside of bariatric surgery. A lot of elective surgeries are done on weekdays, so I wasn't in the operating room as much as normal. I only saw one surgery. It was a neck lymph node excisional biopsy of an AIDS patient who probably developed lymphoma. AIDS is a devastating disease and wrecks havoc on the body. I'm not sure what it is about infectious disease that fascinates me, but I was enthralled with this man's case. I read through his chart (which was basically a novel), and was able to review several infectious agents and the diseases they cause (Cytomegalovirus, Mycobacterium avium, Cryptococcus neoformans, and many more). AIDS completely destroys the immune system leaving its victims vulnerable to all sorts of crazy infections. It is an infectious disease doctor's dream... or nightmare... patient.

I spent most of my 24 hours in the ER working with Traumas and potential surgery candidates. As a student I basically collect the patient's history and perform a physical exam. I am able to formulate a diagnosis and a plan of action, and then present that to the resident. The resident then assesses the patient and changes or confirms my diagnosis and plan. This has been far more exciting for me than standing in surgery for hours at a time holding a retractor or camera. I love talking to patients, seeing the clinical manifestations of disease, and figuring out a solution to solve the problem. Actually fixing the problem (at least surgically) has been less exciting for me. I guess I'm not intended to be a surgeon...

We only had one trauma last night that was very minor. I guy was loading a scooter into a truck and it fell on him. As the trauma team assessed his condition I was able to help by cutting his clothes off, putting in a foley catheter, and cleaning up his wounds. I really enjoyed my night in the ER and I'm excited to spend the next month there. I'm really just excited to see new cases that don't involve surgically altering people's stomachs!

Surgery continues...

I'm half way through my general surgery rotation and counting down the days for it to end. I'm really not loving it and I'm not sure what is wrong with me. The hours are insane and the residents and surgeons are some of the most self-centered, unfriendly people I have ever worked with. If this rotation is a true glimpse into the life of a general surgeon-then count me out!!

I am currently working with a bariatric surgeon. I see lots of gastric bypass surgeries and a lot of complications from previous lap band surgeries. Almost all of the patients I have been working with are morbidly obese and the doctor I work with treats obesity strictly as a disease rather than a result of lifestyle. This perspective has been interesting, but not one I fully embrace. I do believe that certain people are more prone to weight gain than others, but to call it a disease seems strange to me.

Obesity is one of the leading preventable causes of death worldwide and is viewed as one of the most serious public health problems of the 21^st century. A lot of health problems are directly associated with weight: particularly heart disease, type 2 diabetes, sleep apnea, certain types of cancer, and osteoarthritis. People eliminate a number of health problems simply from losing weight. I was reading about obesity as a disease and came across "treatments" for this disease. The primary treatment for obesity is dieting and physical exercise. If this fails, anti-obesity drugs may be taken to reduce appetite or inhibit fat absorption. In severe cases, surgery is performed or a lap band is placed to reduce stomach volume and or bowel length, leading to earlier satiation and reduced ability to absorb nutrients from food.

These seem more like weight management options than disease treatments. In my opinion people have chronic diseases because of weight and not the other way around.

Seeing the surgery side to losing weight has left me disappointed. Surgery isn't the best solution in my opinion. I have seen far too many complications from bypass surgery, eventual weight gain after initial weight loss, and chronic problems from these surgeries. I feel like people choose to undergo surgery before they have exhausted other resources. I saw a surgery performed on a 21 year old! The doctor I'm working with feels like he is curing obesity by doing these surgeries. I think it is wonderful for people who use the surgery to lose weight, get off diabetes and blood pressure medications, and make a complete life style change. However, I have seen too many people who don't do these things and end up worse than they were before surgery.

These two people are heroes around here, and have proven that weight loss is possible without surgery. Mike and Ron from the biggest loser visit Toledo, Ohio!! Click Here!

Babies, Bagels and Bloody Bowels

My pediatric surgery rotation ended last week, and I am quickly finding out how spoiled I was. My new rotation in general surgery is going to be insane. I've been on this service since Wednesday and have worked 53 hours!! I was lucky enough to get Sunday off.

I already miss working with little kids. My last week in pediatrics got really busy and I never blogged about some of the exciting things that happened. Our little preemie who was born at 25 weeks didn't do as well as expected with the drains they put in and ended up perforating his cecum. His X-rays showed a ton of free air in his abdomen - not a good sign. The little one went to the OR as soon as they could get an opening. The surgeon didn't know exactly what was wrong but knew he had to operate because of the X-ray. This was going to be an exploratory abdominal surgery to find out what was wrong. Can you imagine an exploratory surgery on a 25 week preemie?!? This little kid would consider my two hands held together as spacious. This whole experience was surreal. Half way through the surgery I thought I had entered a really bad dream. Here was this little tiny creature with a hole in his belly and little iddy biddy bloody intestines spilling out all over the operating area. They found the defect and sewed the ascending colon to the ileum and began to put him back together. When I left the hospital that day I ran into the parents in the elevator. They were anxious to hear any additional insight into what took place. The mother started crying when I told her the surgeons were very pleased with the outcome. It made me hold my boys a little tighter when I got home that night. I'm so lucky to have such healthy children.

There were plenty of other surgeries during that last week: Intussuception, volvulus, appendectomy, hernia repairs, circumcisions, and the most heartbreaking - perianal wart excision of a 2 year old. These weren't just a few warts. These were finger like projections sticking out of the girl's bum. I don't even want to imagine diaper changes after the surgeon was finished with her. This case almost made me consider becoming an advocate for the HPV vaccine. "One less, one less"

My diet during the pediatric rotation consisted of a lot of bagels. They always had free bagels in the resident's hall. Whenever I had a chance, which wasn't often, I would run up and grab a free bagel. I discovered the free PB and Jelly from the cafeteria condiment bar worked great on the free bagels! PB&J bagel sandwiches!! No free bagels at my new rotation. :(

PICU

If I spend any more time in the pediatric intensive care unit (PICU), my kids won't be able to do anything fun when they get older! I can't believe how many kids have been seriously injured from ATV accidents in the short 2 weeks I have been there. I don't think I want my kids on ATVs - ever. They are very fun, but even with the proper equipment a simple accident can turn deadly.

So kids, stay away from ATVs, avoid climbing on washing machines, always wear your seat belt, and watch out for mom's abusive boyfriend. Those are just a few of the reasons I've seen that put little kids in the ICU.

This week has been slow as far as surgeries are concerned. We have a lot of sick patients to watch closely. If things get worse for any of them they get rushed to the OR. The only surgeries I saw this week were hernia repairs in little tikes. I was prepared to see a pyloric stenosis correction but it was canceled because the baby had an electrolyte imbalance. They will probably do that surgery on Sunday when I'm off. No call this weekend - hooray!

First week finished

With a 24 hour call last night, I spent 79 hours at the hospital this past week. Students aren't to exceed 80 hours in one week, so I guess I had an extra hour to spare. This week has been a rude awakening to clinical medicine. I'm not used to working 11-12 hours everyday!! I've been so tired all of the time. It's too bad I don't drink coffee because I really needed it this week. I'm sure I will acclimatize, but right now I am exhausted.
I've been able to see some really cool surgeries. This week I was introduced to laparoscopy. The surgeon can put a camera into the abdomen and do an entire surgery through tiny openings in the skin! It is really cool to see everything done on the screens. I was assisting with the camera during one surgery and half way through the Dr. asked me to go clean the camera on the kid's liver. So I navigated the camera to the liver, wiped the camera a few times against the liver, and came back down with a cleaner view. It was super weird to clean a camera on somebody's liver.

I saw an appendectomy, repair of a belly button so urine would stop leaking out of it (Urachal cyst), insertion of an abdominal drain in a preemie baby (born at 25 weeks), and insertion of a subcutaneous port. The subcutaneous port is a cool device that allows medicine to be injected directly into the heart without a needle stick in a vein every time. This is helpful in people who get a lot of shots: chemotherapy, regular transfusions, etc.

Surgery

My second day in the hospital was so different than my first. Friday was absolutely crazy! I scrubbed into 4 different surgeries and was running around the hospital all day. For now during surgeries I mostly just watch. Occasionally I help retract things or cut sutures and eventually I'll be able to do more.

Today our attending physician had to go to a different hospital for a complex surgery and left my resident with nothing to do - which left me with nothing to do but study. I'm so glad I decided to pick up some books this weekend. The hospital downtown is really nice and has been a lot of fun exploring and finding my way around. So far I have learned that I really love being in the hospital and I love seeing patients. I'm really glad I get to start with pediatric surgery and have these experiences to compare to working with adults well before my actual pediatric rotation begins later this year.

On Friday I met my resident who grew up in the Bahamas. He's the guy that I will be spending all of my time with over the next four weeks. He's a really nice guy and will be a lot of help. He seems willing to help me learn and is patient when I have no idea what is going on. I chased him around all over the place on Friday. I saw a circumcision, an umbilical hernia repair, an omphalocele closure, a neck abscess drained, and pancreatic ascites fluid drained. We bounced around from patient to surgery to patient and back to surgery. We also saw a little girl who had fallen out of a first story window and hit her head. The CT scan came back normal but they kept her overnight for monitoring. The little premature baby with Beckwith Wiedemenn syndrome is a sad case. He was born with all of his guts hanging out of his belly (the omphalocele closure I saw in surgery), a huge tongue that won't fit into his mouth, and severe hypoglycemia. He has had his guts suspended above him for the past week to prep them to slide back into his abdomen. Friday I saw the doctor sew them back in. It is crazy to see this little tiny body with a surgeon's hands inside it's belly.

Today was so slow. We rounded twice, saw all of our patients and created their plans for the attending to approve, and then sat and waited for him to return from another surgery. While sitting and waiting I was able to get a lot of studying in. We did get a new patient - a 6 year old boy was riding his dirt bike off jumps and crashed directly onto his handle bars. He looked and acted fine - just had a bad stomach ache. The CT scan was super impressive. It showed a huge liver laceration. On a scale of 6 - he was nearly a five. Level 6's are so serious that people with those types of injuries usually die before they can make it to the hospital!! He is in bad, bad shape but it isn't physically apparent. His parents were convinced he had a small tear on the liver that was of little consequence. We had to scare the parents to let them know how serious his injury really is. They have not been very successful in helping their son comply with the Dr.'s orders.

6AM - 6PM is a long day. I was spoiled in school to have one hour lunch breaks. I realize that eating is a privilege. If I have a chance to eat I need to take advantage.

More orientation...

While all the other students got to start working with patients, all of the students on surgery had an additional two days of orientation and lecture. These days have felt even longer than the first two days of orientation. We have had all kinds of lectures: Sepsis, Suturing, Postoperative care, Urology, Breast cancers, Skin cancers, Thyroid cancers and others. We also did some fun things throughout the two days: We were given a complete tour of the hospital, practiced scrubbing in and gowning up, we were able to practice suturing on pig's feet, and they had a number of different procedures for us to practice. Some of the required procedures I must experience before successfully completing this rotation are starting IVs, placing NG tubes, and Foley catheters. They also showed us how to place a chest tube (something we won't have to do yet). I'm sure Mom will just laugh when I say how daunting these procedures are going to be! I have never even given someone a shot and I have to start an IV?? Not to mention thoroughly cleansing someone's nether region to shove a tube up his or her urethra!! I wish I could come to work with you for one day Mom and just do procedures with you assisting me.

The hospital attached to my school doesn't have pediatric patients. I selected pediatric surgery for my first rotation so I will be at St. Vincent's which is a hospital downtown. I start tomorrow at 6 AM!! I have mixed feelings. I am super excited but exceptionally nervous. It doesn't help that I've never been to this hospital, don't know where to park, and will have to wander the halls looking for some lady named Karen who will teach me the scrub in procedure for their hospital. And I don't know how I feel about working with surgeons. During one of our lectures today one of the surgeons told us we went into medicine only for the money or we would have chosen another way to "help" people. He went as far to say that if any of us choose family medicine or pediatrics we might as well learn how to change the oil in our cars so we won't have to pay someone to do it. The stereotype of the arrogant surgeon has already reared its head. Tomorrow I find out who I'll be with for the next 4 weeks and I can only hope he or she isn't as bad as the one who taught that lecture.

I promised myself this blog wouldn't be super negative - I don't mean to complain constantly. I did come home to a wonderful dinner and some amazing kids. My boys are growing up too fast!! Ike is huge - I want that little tike who could curl up on my chest. I was in charge of putting him to bed and Leisy took care of Zeb. When I went to put Ike in his crib the bedroom door wouldn't open!! Zeb had gotten out of bed to play with his toys and totally crashed next to the door. I had to wait for it to get dark (or he wouldn't have stayed asleep) before I roused the boy to get him back in his bed. Silly kid.

Paging Dr. Miller...

My introduction to 3rd year wrapped up today. The orientation consisted of two long days of many presentations by Doctors, Nurses and PhDs explaining various aspects of what will be expected of us as students. I'm really excited to get on the floors and "start touching" patients (as one of the presenters worded it). I'm really nervous about being thrown into the middle of everything and expected to perform. I imagine it will be like jumping out of a moving vehicle and trying to run fast enough not to fall. (I've successfully done this many times but my Dad may remember the time I wasn't so successful at staying upright. Let's hope I don't incur road rash during my surgery rotation!). Topics covered writing orders, working in sterile fields, review of the physical exam, review of generating a working differential diagnosis, dangers of spreading germies (like C-diff) from patient to patient, how to access (and keep private) our patient's electronic records, intro to the radiology department, review of heart murmurs and ECGs, many many many more presentations, and to complete the day a (graphic) video of how to insert a foley catheter.

The orientation was officially over when we recieved our pagers!! Every student was given a pager to carry with us wherever we go. I guess I'm officially on my way to becoming Dr. Miller. At least I will be able to pretend to be Dr. Miller for the next two years.