30 December 2006

Doctor of Medicine

It had been four long years yet I remembered the first day of orientation as if it were yesterday. On that first day, the Dean of Student Affairs called our names. I sat among 125 people who were to become my brothers and sisters over the next four years. The day had started with a breakfast and check-in where we received our little name tags that certified that we belonged there.

I had finished up some paperwork and needed to drop it off in the Administration building so I treked over to this building before my "orientation". When I passed the Office of Admission, I saw five people sitting there with papers in hand. It occured to me that they were waiting to see if any of us did not show up and that they might slide into our seats. I spoke to one of the gentlemen who was sitting there with his father. He said that he was on the waitlist and that he didn't see where he could lose anything by coming here today to see if he could snag a seat. He looked at my nametag and said that he guessed that he wouldn't be getting the one that I held.

One by one, the Deans introduced themselves and gave some words of encouragement. We would be the second class of the new century. We would be molded and shaped into caring physicians who would be on the frontlines of cutting edge healthcare. We were told that for everyone of us standing there, twenty five people wanted to be in the same position. It was heady stuff for some of us who just wondered if we really wanted to be physicians after all. It still wasn't too late to back out and give that young man over at the administration building my seat in medical school.

The doubts took a back seat to all of the preparations. We were photographed (official IDs) and picked up our microscopes, lockers and slide boxes. We also received our syllabi for our first semesters classes. The syllabi were thick and heavy. I also met my "big sib" who was a second-year student who presented me with every one of her books from first year, her notes and used syllabi (all filled in) and her old exams. She said that her apartment was tiny and that she knew that these things would help me. In retrospect, she was my savior that day. I ended up not having to purchase anything for the first day of class except a heavy sweatshirt (The AC was freezing even though the outside temp was broiling).

My big sib walked me through the first semester pointing out every pitfall. She gave me strategies for doing well in every course (especially Anatomy) and reviewed her system for mastery of first year. Others in her class did much of the same when we had our first class meeting. I ended up taking the job of running the noteservice since I had been a graduate student and had some experience with getting volumes of notes out. It turns out that my notes are still used at our medical school especially the physiology notes. I became infamous.

The first day of orientation went by and the first day of classes went by and the first semester of medical school went by. Thanks to my big sib, I had done well and survived. The first two years went by and then the first rotation went by and soon medical school went by. I found myself standing in line wearing my black robe with doctorial hood (draped over my arm) and my doctorial hat trimmed in green complete with gold tassle. I was about to graduate and become a Doctor of Medicine.

We marched into the graduation hall (to the strains of Pomp and Circumstance) that was packed with family and visitors. My father who had been a physician had died before I had applied to medical school. He always knew that I would be a physician even though I had stubbornly refused to consider medicine as a career. I had been a research scientist because I wanted to discover new truths. Little did I know but medicine was about truth every day.

My uncle, who had been an Batallion Surgeon in the Korean War, placed the hood over my head. He stood at his finest military attention as he and the Dean pronounced that I was now a Doctor of Medicine. I distinctly remember a chill as my name was pronounced with "Doctor" in front of it. I was so different from that woman who stood in orientation on that first day with fleeting thoughts of giving up my seat in medical school.

When the ceremony was over, I looked at my degree (the thing is huge) which was written in Latin. I still have to look at it from time to time to convince myself that I had actually finished four years of medical school. All of the tests and all of the experiences had molded me into to a newly minted physician. I had two months to move and get ready for internship (the time of my life).

When I think back over some of the things that got me through medical school: First, I don't complain. Complaining doesn't get the problem solved and only prolongs the agony. I identify the problem and think of several solutions. I never present a problem without presenting at least two solutions as I see them.

Second, medicine is very difficult and I wouldn't have it any other way. Nothing good comes without sacrifice and struggle. This job is a day to day learning experience that never ceases to amaze me. I often feel as if I have a "window on the world" as I treat every patient. My patients have been my teachers and my links to all humanity.

Third, any medicine is always my job. When a colleague drops the ball, I pick it up as quickly as I can. When something is not done, I get that something done as quickly as possible. We are here for the patients and not for ourselves. Instead of getting angry, I get busy and get the patient taken care of. I practice medicine because I WANT to practice medicine. The patient comes to the hospital because the NEED to come to the hospital. I have the choice, the patient does not have a choice. On my service and in my practice, there is no room for laziness or excuses. Things have to be done and on my watch, they GET done because after all, I am their "Doctor of Medicine".

26 December 2006

Christmas at the Hospital

Christmas comes to the hospital in a manner far different from the shopping malls. Usually the patient census is lower because most attending physicians want to get their patients home for the holidays. It is a well-known fact that people heal much faster at home among familiar surroundings than in the hospital. Exceptions to this rule would be people who are incapable of caring for themselves or those who have no one at home to help with their convalescence. Sending any patient home to an empty house where they have no groceries or means of even preparing meals is not going to assist in their recovery. That being said, most people are happy to get home ,holiday or not, to their familiar routines.

I usually volunteer to work on Christmas. My family has a huge celebration to welcome in the New Year so Christmas generally takes second place to the New Year's celebration. I also LIKE being in the hospital on Christmas. There are decorations and most people are in a festive mood even if they are hospitalized. Rooms are usually decked with little Christmas trees and and cards with loads of red and green. The staff is generally upbeat because by Christmas Day, one is over the grumbling and disappointments of not being home for the holiday. I have found that the folks who work the evening and night shifts have little disruption to their holiday activities. The folks who are working during the day shift are usually younger and have plans for the evening and night anyway. Christmas is a pretty nice day in the hospital.

In our departement on Christmas, or any holiday for that matter, the chiefs and one intern will take care of their services. We round on the patients and get needs taken care of. Since the operating room is only taking care of emergency cases, we can generally get most things done and get home unless we are on call. If there is an emergency case, the call team will take care of it. Most of the time, it's something like an appendectomy or an occasional strangulated hernia that the patient has been trying to ignore over the holiday. On a couple of occasions, I have had things like a ruptured abdominal aortic aneurysm roll in though the door. All in all, you are not going to be operating unless something needs to be done in a hurry.

The Operating Room staff will make plans for brunch or dinner on Christmas. Usually one of the attending surgeons will have some food sent in for the folks who are working on Christmas. They are happy to share their food with the resident staff, which is a nice thing to do. Many of the larger surgical or medical practices will have sent gift baskets and fruit baskets to various floors in appreciation for the work that the nursing staff does. One of our thoracic surgeons has a catered party for all shifts on the floor that takes care of his patients. It's pretty nice for the staff. Even as an intern, I was always invited to "share the chow" with the nurses. Usually, I wanted to rest in bed because the night might get busy and being rested was a good thing.

The week preceding Christmas was generally a time of holiday vacation for most of the clinic staff too. Patients were not scheduled unless they needed something that couldn't wait. Usually there would be a party after we had seen a couple of patients that needed treatments on a regular basis. The week after Christmas would be brutal but some of the wiser office managers had developed the practice of making the schedule after Christmas a bit lighter and the week before Christmas a bit heavier. In either event, working the clinics around Christmas wasn't bad. Some of the regular patients would drop off chocolate, which made the days even more pleasant.

Some of my colleagues started their annual "grumble" from Thanksgiving to Christmas. They wanted to go home (California or overseas) for the holidays and a week just wasn't enought time for this kind of travel. Our program director was pretty flexible about time off around the holidays as long as services were covered. If someone wanted to take a couple of extra days, we worked out a schedule where we could accomodate everyone. Still, there are folks who would complain that the schedule is "unfair". Again, I always volunteered for Christmas Day or Christmas Eve and was happy to be off New Years Eve and New Year's Day. By my third year of residency, the holidays were a welcome break in my routine and I would "go with the flow".

Our department would have an elaborate Christmas party. This would be held off hospital grounds (read alcoholic beverages involved) and would be a "dress-up" affair. It gave some of us a welcome change from the scrubs and minimialist atmosphere of our everyday life. It was also an opportunity to meet some of the spouses and significant others of my colleagues. Sometimes this affair turned into the "coming out party" for some of the couples that had developed from July to December. One of my favorite tasks was taking bets on who would last through New Year's Day. Many times, the week off during the holidays took care of the relationships that had been so feverish right after residency started.

Christmas was not an especially heavy time for traumas. If the weather was bad (ice storm or heavy rains), we would get an occasional motor vehicle collision victim but most of the time, people stayed home and the bars were closed. I remember an very sad Christmas night when a family was returning home for a day trip. The father was driving and feel asleep at the wheel of the car. The mother ended up being declared brain dead and all three of the children were killed. Only the father survived. One of the children and the mother became organ donors so that many people were helped that Christmas by the generosity of this grieving father who had lost his entire family. It was't weather or alcohol that had caused this collision, it was extreme fatigue. Christmas can be a day of tragedy sometimes too.

I remember one quiet Christmas evening. I was resting in my call room (half watching the Food Channel) with my eyes closed. I had told the charge nurse in the Intensive Care Unit that I was going to take a nap so just call into the room instead of paging (faster anyway). She would also make sure that her staff didn't page for trivial things that could wait until I finished napping. When I am the ICU resident, I always round every four hours and take care of loose ends. Most of the nursing staff will keep a "scut sheet" at the bedside for things that they need or for things that they want to bring to my attention. I also check vitals, lab values and make sure that all of my orders are up to date too. This makes signout in the morning and round much faster.

On this quite evening, I napped for about 30 minutes and then got up to make my rounds. I got a call from the chief resident that he was bringing up a very unstable patient that was a ruptured thoracic aortic aneurysm. He was through the door with the patient within three minutes. The intern appeared and begged me to let her put in the monitoring lines (arterial and central) so we got to work. I put in a subclavian central line as she placed a radial arterial line. The OR called to say that they were ready as the attending cardiothoracic surgeon came through the door. While he was speaking with the family, the chief resident and I wheeled the patient into the OR, the patient was in full arrest and had little blood pressure according to our arterial line. The chief told me to scrub and get ready to open the chest.

This was my first median sternotomy and I shook as I opened this patient's chest quickly. Once the chest was open, we saw that this patient was beyond repair. There was a 50-cent sized hole in his ascending aorta that had dumped blood into the chest. We examined the rest of the aorta, which was quite friable. At this point, we pronounced the patient and I closed the chest with one of the physican assistants. Our attending physician told us that he would dictate this case since it was a fatality. I had literally opened this patient's chest and placed my finger in the large hole in the aorta. The heart was empty of blood and silent. We didn't even have enough time to get the patient on heart-lung bypass which might have bought us some time.

When I had completed the chest closure, I changed into clean scrubs and slipped out of the back door of the operating room and up the elevator into the ICU. I told the nurses about the case and checked all of the patients who had been covered by the resident in the unit upstairs. Since neither of us was particularly busy, he had volunteered to cover my unit while I scrubbed this case.

Christmas can be a time of looking at life and death up close. It can be a time of learning for a fledgeling resident who was beginning to hone her craft. I know that that family will always associate Christmas with the death of their loved one. I had found out later that this patient had known about the aneurysm but had cancelled every appointment for scheduling repair over the past month. The patient wanted to schedule the repair after the holidays but had begun having chest pains on Christmas Eve. This patient didn't want to "trouble the family" with their illness.

22 December 2006

How Do You Stay Awake?

Many times I have been asked how I stay awake and answer calls overnight. I don't have a specific "system" but I have some things that help me remain alert when I have to remain alert. Being on overnight call is physically and emotionally draining at times. You never know what will be at the other end of each page. For me, not knowing what to expect with every page is one of the more interesting aspects of medical practice.

First, let me dispel some myths. It is a myth that a resident physician in training has to go for 36 hours straight in order to learn how to deal with emergencies. I have had few emergencies when I was on my 36th hour. What may seem as an emergency when presented to a physician who is sleep deprived becomes a major annoyance. One simply cannot do their best work after 36 hours of work without rest. Medicine suffered before the institution of work hour limitations and no amount of complaining by attending physicans who were trained under the "old system" will negate that fact. Most of the times, the residents and the physicans were lucky that they didn't harm more patients because of lack of sleep.

It is a myth that every night on call is a "race against death". Most of my on-call nights are spent dealing with problems that either came in through the emergency department or were left over from other services during the day. With the 80-hour work hour limits, some services are not going to be able to take care of all of their work during the day and get their operative cases done too. It become the work of the on-call resident to finish any needed work in terms of the services that they cover. The patients that I cover overnight are MY patients during my watch. I am happy to take care of their needs and help my fellow residents.

Still, there have been times when I have been so sleep deprived that I bordered on being depressed. I am mostly affected with I am not busy but just waiting for the night to move on and for the frenatic activity of just before dawn to begin. If I am busy, the night goes by rapidly and the exhaustion doesn't hit until I am ready to hit the bed. On nights of extreme exhaustion, I go outside and take some deep breaths of air that has not gone through the HVAC system of the hospital. One of the nicest places to take some deep breaths of fresh air and survey "my kingdom" is the roof of the hospital. If the weather is rainy or misty, the cool moisture against my face is great. If snow is falling, there is a fresh, crisp, and quiet calm that is invigorating. If there is fog, there is an eerieness that is wonderful. Summer, spring, fall or winter, I can't lose on the roof.

There is a certain amount of "sleep deprivation" that you learn to live with. For me, it started in medical school when I quickly learned that I would have to be able to study regularly with less than 6 hours of sleep. The volume of material to be mastered in huge and this mastery takes time. I learned to study when I was tired and I learned to do things such as aerobic exercise that would keep me alert and make my studying more efficient. I also learned that caffeinated drinks like coffee, tea, Mountain Dew and Diet Coke, did not keep me awake but only make me more nervous. Sugar was out too as it gave me a rush but then a drop where I found myself more energy depleted.

Hydration became a goal for me. I found that I felt less tired when I was adequately hydrated. This meant keeping a bottle of water in my lab coat pocket at all times. I also kept a Brita water pitcher in my call room and kept it filled with water. As most hospitals are hot and dry, I found that I have to work to keep myself hydrated and that dehydration is the enemy of efficiency.

I always hear my pager. I don't know why I have always been able to hear the thing beeping but I have never missed a page when my pager was working properly. I also made it a habit of letting the page operator know the number to my call-room in case my pager was not working. He/she always knew how to track me down if the paging system was off. We could sign out our pages to the residents who were in the house overnight or leave a phone number where we could be reached. I just never sleep deeply at the hospital or at home so that I do not hear my pager.

When I have found myself so exhausted that I was just not interested in anything except sleep, I took a nap. First, I would take a brisk walk and then I would nap for 20 minutes in the large lounge chair in the surgical lounge. Those 20 minutes would bring me back refreshed enough to get through the rest of the night. Taking a shower worked well also. I never did morning rounds without a shower, tooth brushing and change of clothes if I had been on call overnight. There have been times that I have literally left the OR, headed for the shower and then to AM rounds. Life just works out that way.

When a nurse pages me, I have always kept a pencil and paper handy to write down the patient's name, the service and jot down the time. I keep a running tally of my calls overnight so that I know exactly when I was paged or how many times I have been paged. These tally sheets have come in handy more than one time during Mortality and Morbidity conference. My first rule has always been to "Go and evaluate the patient if I am not familiar with the problem." Most of my problems these days come from a more junior resident who needs another pair of eyes or hands in terms of evaluating their patient. I am only happy to help as I vividly remember being in their shoes. Most of the time, they have solved the problem before I get there but it is always nice to have a backup when you need a backup.

Most nurses (99.99%) do not call a resident in the middle of the night for things that are "trivial". Occasionally, I will get a call to speak with a patient's family member about the plan for the patient. If I am not the resident on service, I can only offer support and a willingness to pass along the concerns to the service in the morning. If a nurse calls, they have a problem and I appreciate the calls. The nurse is at the bedside and I am usually in the call-room. Most of these calls can be taken care of by phone but many times, I have to go and evaluate the patient. My rule is this, if I think that I "ought" to see the patient, I "go" and see the patient.

When I am on-call, I plan my evening and next morning and write down those patient care plans. I know that I am not going to be doing late cases (unless there is a dire emergency) so I get everything squared away for my service. Before I leave post-call, my junior residents and students know exactly what they need to be doing for the day. The senior on-call resident gets a list of my patients and potential problems with solutions so that they have a better idea of what has been happening on my service. I also chat with my attendings so that they know what I have planned for the day.

With the new limited work hours, we have to have excellent communication with our colleagues and with our attendings. We also have to be able to anticipate what our patients will need and make those provisions. As residents, we have to get to a higher level of efficiency faster than before when we had the luxury of more time in the hospital.

I don't think that I am getting any more sleep these days than in medical school but the work is more interesting. Gone are the days when I could go "drinking with my mates" for an evening or watching the telly for hours. I have loads to read and study most of the time. Still, there are nights when I have to fight to stay awake and fight to keep my concentration. Usually, I take a deep breath and keep on plugging away. That clock never stops and soon my work will end. It takes the same amount of time to do a job well as to do it poorly. I just cannot do anything that involves one of my patients poorly.

20 December 2006

My first case in the Trauma Bay

Here I was, fresh from my course in Advanced Trauma Life Support (ATLS). The trauma pager had gone off while I was finishing up my final sign-out note. I quickly jotted down my last thought and headed down to the Emergency Department to the main Trauma bay.

"Whose the chief surgery resident?" shouted the Emergency Physician. "I am" and I stated my name for the recording nurse to add to the sheet along with my time of arrival. I slipped my lab coat off and slipped into my trauma gown. I pulled my OR cap out of my hip pocket and placed my goggles in place before I donned my two pairs of surgical gloves.

I quickly surveyed the equipment in the room. Airway tray check; thoracostomy tray check, central line tray, check. I was set. My intern arrived and stood on the other side of the bay. He was ready to assume his place and insert a central line. The large bore IV lines were hanging hooked to the fluid warmer.

The Emergency physician told me that the paramedics were in route with a 30 year old man with a gunshot wound to the head. He had been intubated in the field and had two 16 guage IV lines in place. He was found in the bathroom by his wife who was preparing their evening meal when she heard the gunshot. She found him on the bathroom floor and dialed 911. The paramedics were across the street having dinner when the call came in. They were on the scene within 3 minutes of receiving the call.

My patient arrived being ventilated with a resuscitation bag. I quickly listened for breath sounds and noted that there were none on the left side. I pulled back the endotrachael tube and heard breath sounds on the left. Both IVs were infusing with lactated Ringers solution and the patient had received 500 ml in each arm. The paramedics reported a blood pressure of 80/60, wrapped the head while inserting IVs and intubating. They scooped and headed for my hospital. The patient lost blood pressure in route but quickly regained pressure with CPR and wide open IV fluids. Approximately 15 minutes had passed since the call went out.

I instructed the nurses to place the IV bags on pressure and infuse wide open. I noted a single large gaping wound in the right side of my patient's head in the frontal area. I unwrapped the head and found the exit wound just behind the left ear. There was brain tissue and blood oozing from the exit wound. The patient's blood pressure was now 110/80 with a heart rate of 100. The patient's right eye was swollen and blackened. Neither pupil was reactive. The rest of the physical exam showed no other injuries.

C-spine radiographs and chest radiographs were taken and bloods were sent from the central line that the intern had deftly inserted in the patients right femoral vein. The C-spine came back negative and the chest film showed that the endotrachael tube was in good position with no pneumothorax present.

By this time, the trauma attanding surgeon had arrived and we headed for the CT scanner for a CT of the head. The patient's vital signs had remained stable after 2 liters of IV fluids so I cut back on the infusion rates. The attending physician went out to deliver the grave prognosis to the patient's wife. By this time, 20 minutes had passed since the patient first arrived in the trauma bay.

The CT scan showed that the bullet had passed through the brain and left massive damage. The patient showed no reflexes but vital signs were stable, urine output was excellent. The neurosurgeon arrived and agreed with our assessment that the gunshot wound was fatal. "Was there an organ donor card", he asked.

When the patient's weeping wife came into the trauma bay, the first thing that she said was that he wanted to donate any organs that he could donate. His drivers license confirmed what his wife had said. She said that she had notified their children who were at their grandmothers house and that they would be on the way. My attending physician notified the Organ Donation System and thus the process began.

My patient had given no outward signs that his wife could remember of his impending intention to shoot himself. She said that he had been joking with her about her overuse of garlic in the marinara sauce that she was preparing for their evening meal. She said that he had come home from work about 30 minutes earlier and showed no signs of distress. She also indicated that she didn't even know that he owned a gun and had never recalled him even discussing owning a gun.

When the family left to speak with patient registration, I informed the Trauma Intensive Care Unit that this patient would be coming up and would be prepared for organ donation. The bed was ready and the organ donation coordinator was ready to speak with the family. As we moved the patient up to the ICU, the family met with the organ donation coordinator.

My attending instructed me to perform an apnea test (a test to gather evidence of brain death). A neurologist, after examining this patient, confirmed that our patient was indeed brain dead after examining the findings of my test and others. The neurosurgeon concurred with the findings and the organ transplant coordinator took over the care of this patient. Brain death was established within 4 hours of admission to the Trauma Intensive Care Unit.

The patient's heart, liver, pancreas, kidneys and lungs were harvested and went to patients that were in our hospital. It turned out that this patient ended up donating tissues and organs that eventually helped more than 20 people. His skin and bones were also harvested and sent to tissue banks. His eyes provided cornea transplants for two people who had been waiting for corneas.

My patient has been laid off from his job the week before he shot himself. He had been leaving his house every day and had not told his wife that he no longer held a job. He had purchased the gun the day before he took his own life. He had never been depressed and had never spoked of taking his life or feeling hopeless. He had worked at the same company since graduating from college at age 21 and had moved up to the rank of assistant manager.

According to his wife, he had been instrumental at his company in getting many of his fellow employees to sign organ donor cards. He felt strongly about organ donation and many of his fellow employees had come to the hospital when they heard of his injuries. The waiting room was filled with friends and relatives who spilled out into the hallway and in front of the elevator.
One by one, they filed into his hospital room to say goodbye.

My first trauma as trauma chief will always stick with me for many reasons. First, this man apparantly made the decision to take his life shortly after being laid off from work. He quietly went about the planning and execution stage of this act. Second, the paramedic crew was directly across the street from his house when he shot himself. One of the paramedics believes that he may have heard the shot but is not sure. They were one the scence very quickly. Third, this was a well-loved man who was generous in death after committing the ultimate selfish act, that is taking his life.

For many weeks, I would pass the Trauma Bay and I could still see him lying there with head bandaged, right eye swollen and bruised but the rest of his body in perfect condition.

10 December 2006

How I chose surgery

I can vividly remember starting my third year of medical school. My school chose our third-year schedules for us and I remember some of the angst of my fellow classmates when our schedules were posted during the summer between our second and third years. I was in the midst of a wonderful Pathology fellowship that I had received for scoring very high in my Pathology course. I was assigned to various Medical Examiners offices and to the Pathology Departements of a couple of very large teaching hospitals. I had been spending the summer doing everything from crime scene investigation to transfusion medicine to bone marrow transplant. It had been a great summer. I was very strongly considering Pathology and Transfusion Medicine as my specialty.

I stopped by my Dean of Academic Affairs office and was told to wait for my USMLE Step I scores. The school had received them before I had received them. I took a deep breath because I really hadn't prepared myself for facing the prospect that I might have failed that test. I sat in a chair outside the Dean's inner office and ran a couple of scenarios as to what I would do if I had failed. I would quickly sign up for a retest and I would only miss one rotation at the start of third year. Since I was doing Pathology, I could study in between cases and get my preceptors to help me with covering the material.

The Dean came out and handed me a sheet of paper. I had to just sit there in disbelief. Not only had I passed, I had done extremely well. I was on my way. It was hard to hold back the tears of joy because I had studied about two and a half weeks for Step I. My fellowship had the requirement that I take Step I by the second week in May and my last exam from second year was on April 28th. I would be starting third year and I would be starting third year on Pediatrics with one of my best friends as my rotation partner. Life was good... I found out later that two people from my class did not pass USMLE Step I. It was very sad because one girl ran down the hall screaming and sobbing when she received her score. That put loads of people on edge.

I started third year on Pediatrics. It was a good rotation and I received Honors. I really enjoyed taking care of patients and I was very popular with the residents because I could place IVs and draw blood. I had also spent loads of time with an excellent pediatric pathologist so I knew my congenital defects inside and out. I could interpret cath reports and I was quite comfortable in the Pediatric Intensive Care Unit. I had been a Pediatric-Perinatal Respiratory Therapist before starting medical school so the interns found me quite useful.

My second rotation was Psychiatry. This was one of my best required clerkships. I knew that I wasn't going into Psychiatry (you know these things early) so I was free to enjoy the rotation and pick up anything that I could. My preceptor was an excellent Consultation-Liasion Psychiatrist who exposed us to everything from the wards for the criminally insane to hard-core substance abusers to schizophrenics and other stuff. I earned another Honors grade and got some excellent experience. I learned above all that I was not crazy, my friends are not crazy because I spent loads of "quality time" around people who were genuine crazy.

My third rotation was Family Medicine. I had a great preceptor who even delivered babies. This rotatation was entirely office based but I learned to do prenatal exams and care for entire families. I also learned how and when to refer which is great stuff to know. My preceptor was extremely brainy and "pimped" me on just about everything. Turns out this was a good test for USMLE Step II because we either discussed or I had to report on most everything in Family Medicine that was on the shelf exam or on USMLE Step II. I received Honors for this rotation but decided that I really did not enjoy being out of the hospital too often. I also did not enjoy the slow pace of the office.

Holiday break came and I was happy to be done with shelf exams and rotations for five weeks. I knew that Surgery was coming up and my friends had warned me to be ready for two months of pure hell. The rotation is designed so that you spend your first month on General Surgery on one of two services: Trauma or General Surgery. I drew Trauma out of the hat and I received the condolances of my classmates. I figured, "you can do anything that you want with me but you can't stop that clock." No matter how bad, in four weeks, it would be over.

I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn't wait to be on call every third day. I had the time of my life and I loved everything about surgery.

My next month was spent on ENT and then on Cardio-thoracic and Vascular Surgery. I scrubbed every case that was assigned to me and many cases that were assigned to some of my colleagues. I becamed hooked on Vascular Surgery during that rotation. I loved the detective atmosphere on Vascular and loved taking care of the patients. My chief resident on Vascular taught me some great pearls about making sure that even with an amputatation, fashioning a well-constructed stump can make the difference between ambulating and not ambulating for the patient. It was great stuff.

After Surgery, I rotated through OB-Gyn. I hated everything about this specialty. This rotation became my only High Pass during third year. I just couldn't get into delivering babies and I wasn't thrilled with tubal ligations. I wasn't thrilled with spending too much time in the clinics and offices. The one bright spot was the Gyn surgeries which I excelled at. I learned the surgical anatomy like a sponge but I knew that this was not going to be the specialty for me.

I finished up on Medicine and Neurology. This would be my final sixteen weeks of third year. I was fortunate to have medicine last because this made study for USMLE Step II a snap. I totally enjoyed Medicine and Neurology but my heart was back in surgery. All of my Pathology experience really paid off because I aced these rotations and moved onto fourth year.

My faculty advisor was chairman of surgery and helped pave the way for my entry into this specialty. I was also co-president of the Surgical Society during my fourth year which also helped. My USMLE scores were good so this helped too. I had some awesome interviews and I landed at a great residency program. My experiencs began there and they keep on.

As I continue to write, I will be posting more of my experiences.

06 December 2006

The Uninsured Patient

My fiance is a fan of green tea. I have been shopping for his favorite green tea and my favorite hot sauce at a small family-owned Asian market near my house. Since I am in the store at least once per week, I have been introduced to many new tastes and foods by its very-knowledgable owner. Having something of an advertursome palate and being a lover of travel and new cuisines, I always appreciate the discussions and tastings that the owner offers regularly.

The owner of this store is a 50-something gentleman from Korea. He has a wife and three children who are high school and college-aged. He and his wife take turns in the store and I have gotten to know them all in a neighborly sort of way. They are hard-working and offer a very wide variety of great items in their spotlessly clean market. They will special order items for customers at request too.

Some time ago, I was called to the Emergency Room after the intern on my service had seen a 50-year-old gentleman with abdominal pain. The intern had completed his patient history and physical exam and had told me that he suspected that the patient might need surgery (likely gall bladder problem). He had reviewed labs and wanted to discuss the case with me so that I could notify the attending surgeon on call.

When I arrived in the Emergency Department, I found my beloved shopkeeper in considerable pain and agreed with the intern, that the patient would likely need surgery. We ordered a some tests (Right Upper Quadrant Ultrasound) and I relayed the case to my attending who agreed with out plan. I informed the patient of our plans and what to expect in the next few hours. I also made liberal use of pain medication as indicated.

Our patient continued to have a significant amount of pain and the right upper quadrant ultrasound did reveal gallstones so we added the patient onto the end of the day schedule. He was in good health and had been having some indigestion from time to time but nothing that kept him out of the shop or that he felt the need to consult a physician for.

The patient was prepped for a lap cholecystectomy (the usual procedure) and was given IV fluid hydration along with pain medication. The anesthesiologist was happy with administering a general anesthetic and the patient had given consent for the surgery after all of his questions were answered. His wife arrived after closing the store and sat at the side of the stretcher in the anesthesia prep area. She said that she was happy that I would be doing the surgery and liked the attending surgeon very much.

As we proceeded with the surgery, we found that the patient's gallbladder was gangrenous and friable. We converted from the laparoscopic procedure to an open cholecystectomy (happens in about 5% of cases anyway) so that we could get the gallbladder out safely under the conditions that we had found. The case went smoothly and I accompaned the attending surgeon out to speak with the patient's wife while the intern finished closing the incision and writing post operative orders.

When we spoke to the patient's wife, she told us that they didn't have any insurance. They just poured all of the profits from their store into providing necessities for their family and college tuition and had dropped their health insurance. Both had been in good health but things like mammograms for the wife and regular exams were had not been done. (Not that these things would have prevented the gallbladder problem anyway).

My attending told the wife not to worry because we would keep the costs as low as possible and the hospital would pro-rate charges based on the patient's ability to pay. My attending told me as we walked back to the recovery room, that he would not charge the patient for his professional fees under the circumstances but this would be an expensive illness for this previously healthy gentleman.

Our patient made an uneventful recovery and was released from the hospital, feeling better but walking a bit slower. He returned to our office the next week for a wound check and two weeks later, I saw him in the store helping his wife take care of customers. He was doing great even though we had asked him to not work for at least three weeks. He was worried about his business and wanted to at least work half a day.

Two months later, the store closed. The family was not able to make the payments for the hospitalization and keep up with the store. My beloved shopkeeper had lost his business and was in danger of losing his house had it not been for a business associate who had hired him to work in another store.

My patient lost his business because he was not able to afford health insurance for himself and his wife (his children were insured). He was hard-working and contributing to the economy of our locale and country by operating a store. Yes, he took a chance and lost but why not put out best and brightest folks on solving the problem of providing basic healthcare for the uninsured patient.

I am not an advocate of a "federal program" for taking care of this problem. One need only look at Medicare and Medicaid to realize that having the "feds" do anything is not cost-effective and more costly. Why not have an "Apprentice" type show where folks come up with solutions to this problem? It's not as sexy as a multi-million dollar real estate deal but it's a huge problem where we all could benefit.

There are millions of folks out there like my wondeful shopkeeper who contribute to the economy and provide a wonderful service in their neighborhoods. These are hard-working folks who want to provide for their families and keep a roof over their heads. They are not looking for a "government handout" but some kind of affordable insurance plan that would take care of their basic needs and emergencies.

05 December 2006

Medicine From The Trenches

This is my first post. I wish that I could say it will be something momentous but it a bit of an introduction. At this stage in my career, I am a resident. I am about midway through my training and I have been awestruck with some of my day to day experiences with patients. No matter what, I always learn something from them and many times, they touch my life in a way that I feel humbled to have the privledge to participate in their care.

I titled my blog, "Medicine From the Trenches" because many times I feel like I am in a war. It could be a battle with the clock (I have 30 hours of work and 12 hours to get the work done). It could be a battle of wills (I am going to get something into my intern's head even if it kills me and him). It could be war with the "Sandman" (I am so sleepy but I have more patients to see and more fires to put out).

I am going to post my thoughts on the practice of medicine and what I think it needs. I welcome comments and your thoughts on what I have written. Believe me, I am having the time of my life. I love what I do but sometimes when I am tired, I get depressed and after a couple hours of sleep, I am back to my usual cheery self.

A small bit about me: I went to medical school and now I am in residency. I am female and I am a combination of my father (who was a physician) and my mother (who married a physician). I am half Jamaican (my father looked exactly like Harry Belafonte) and half English (my mother was a carrot-topped, freckled faced Englishwoman). They met during World War II and came to the United States. I was born here but I was essentially raised as a Brit.

Well, let's see where this takes us.