The Lone Star State

Howdy from the great big, hot state of Texas!!

It was so hard to leave my family on Sunday! I had to choke back the tears as I waved goodbye to Leisy, Zeb and Ike from the window of my airplane. I was in full uniform and I didn't want everyone to think I was leaving to Iraq for several months. I'll only be gone for 28 days! However, with only three behind me 28 seems like an awful long time.

I was so nervous about putting my uniform back on. What if I wasn't wearing it properly? What if I forget to salute someone? What if I get yelled at for not doing something properly??? But once several people in the airport thanked me for my service I remembered how much this uniform represents and how lucky I am to wear it. People stepped out of line to shake my hand, or to tell me good job, or just to tell me how beautiful my family is. Tonight after a busy day of running around trying to get proper computer access and security clearances for both hospitals, I stepped out of my car just as the National Anthem started. I stood at attention and saluted all alone in the parking lot. A sense of pride filled me, and I realized again what an honor it is to wear a uniform that represents the courage and bravery of so many Americans.

I'll be rotating in general peds and pediatric infectious disease while I'm down here. The San Antonio program is a combined Army/Air Force program. I will spend half of the time at Wilford Hall Medical Center and the other half at Brooke Army Medical Center. The docs I will be working with are all really cool. I met most of the pediatric team this morning at morning report. One of the infectious disease docs is Mormon! He seems really cool but will be leaving to Haiti next week so I won't get to work with him. (If I stay in the Air Force long enough I may be able to go on several mission trips like he has!!) I am anxious to actually get started now that I have been here doing nothing but busy work. I'll spend tomorrow morning in the NICU and the afternoon in the peds clinic.

WHMC (Left) BAMC (Right)

The heat is super intense. Everyday is over 100 degrees. I'm not sure if Leisy could live here during the summer. She may need to take extended vacations if I end up here!! Yikes!! San Antonio does seem really cool and has a lot of fun things to do for visitors! I'll go check out the sites this weekend. The Alamo, the famous river walk, Sea World maybe??? Anybody been to San Antonio and can suggest cool things to see?

A 66 yo white female presented to the urgent care with 10 days of of increasing pruritus (itchy skin all over), yellowing skin and white part's of eyes, and pale stool. She is admitted to the hospital because of jaundice. The patient has felt fine and her only complaint is being itchy. She has no past medical history and has never been hospitalized in the past. She has never had any history of gallstones, hepatitis or cirrhosis. She had never smoked and rarely drinks alcohol. Physical exam is essentially normal except for discoloration of skin and scleral icterus. She had no abdominal pain on exam. She had tons of labs done but I'm just including LFT's:

	Results	Units	Reference Range
		TOTAL BILI	7.2 H	mg/dL	.2-1.2
		DIRECT BILI	4.8 H	mg/dL	.0-.3
		ALBUMIN	3.1	g/dL	3.1-4.7
		ALKALINE PHOSPH	816 HH	IU/L	40-125
		ALT (SGPT)	305 HH	IU/L	4-42
		AST (SGOT)	257 H	IU/L	10-39
		TOTAL PROTEIN	7.3	g/dL	6.0-8.0

Which of the following diagnoses is most probable and which, if present, has the worst/best prognosis?
A. Choledocholithiasis
B. Pancreatic cancer
C. Klatskin tumor
D. Liver cirrhosis due to a combination of hep B and C
E. Gallbladder cancer

Amazing!!

Toledo Dr. will take team to Haiti for help

Dr. Paat is one of the amazing doctors I have had the chance to work with out here in Ohio. He is such an incredible person and a great physician. He is a great example to me. I wish I could drop everything and head to Haiti right now!! ($20,000 just lying around wouldn't be bad either). Click the link and watch the news report. He is an awesome guy.

My pediatrics rotation ended before Christmas break and I already miss working with little kids! I'm now on Internal Medicine for the next three months. My first 2 weeks of outpatient clinic have flown by. Time is marching steadily on and I am freaking out trying to get all of my military rotations scheduled and lined up for this fall. I'm trying to get everything squared away before I start working in the hospital in February. I'm going to be working longer hours and won't have extra time to work on scheduling rotations.

I have been working in a general internal medicine clinic, an infectious disease and nephrology clinic. One of the biggest signs that I was no longer working in Pediatrics was the difference in "prizes" people get at the doctor's office. Little kids get to look through baskets of toys and stickers after they see the doctor. Some age groups actually get books after they have seen the doctor! I loved finding out what the kid's favorite cartoons were while I examined them so I could hand select the books! Adults in the infectious disease clinic get baskets full of condoms to look through. They are just sitting on the table in a little basket identical to the baskets that used to be full of stickers! They're just hanging out in all of their crazy varieties: all sorts of flavors, glow in the dark, his'n'her pleasure and MEGA!! At least in adolescent medicine they were discreetly hidden in a jack'o lantern trick or treating bucket.

Another major difference between pediatrics and adult medicine has been dealing with patient's apathy about their health. Most little kids want to get better, and if they don't their parents sure would like them to. Adults, after some predetermined age, no longer care about their health. Taking care of one's health just seems to be too big of an inconvience after some mysterious time. I saw a guy with end-stage kidney disease, COPD, high blood pressure, elevated cholesterol, congestive heart failure, depression and a myriad of other problems. We were meeting with him to discuss why he couldn't breathe at night when he lays down to go to bed. He wanted that fixed but seemed irritated when he was reminded that he has been delaying kidney dialysis, gained 20 pounds since his last visit, and wasn't taking his medications like he should!! I need to discover a new perspective during this rotation. How am I going to find the desire to help those who aren't willing to help themselves??

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. :(