Archive for October, 2008

crazy awesome

Posted in medicine on October 30, 2008 by whenispark

yesterday i had the joy of not only viewing but also actively participating in a “laparoscopic salpingoophorectomy” which is a fancy-schmancy way of saying we’re taking out a tube and ovary.

as the surgery began, i took to my usual post between the patient’s legs to push on a tool that would suspend the uterus in air within the patient’s abdomen.  it’s an easy task, and i have never minded doing it because unlike retracting, it requires no physicial exertion and still affords the opportunity for the medical student to watch the surgery.

yesterday was different though.  as i stood there, the doctor asked if i would like to stand up at the side of the table.  flabbergasted at why this would be an option, i asked him what he would do. 

“i’ll stand there and hold the uterus up while you come down here.”

“why would you do that” – as i start to edge back from my trusty position.

“because i want you to come here for residency you twit.”

well, that was more than enough reason for me as i scurried around the table to my new post.  and there i stood.  my first task was putting in a new trocar, and i managed with no difficulty, both in making the incision and in placing the trocar.  next was helping out by grasping the appropriate structures.  it was a little strange getting used to it at first because you’re obviously watching a tv screen where everything you do is reversed, much like watching it in a mirror.  the rush was unbelieveable, and despite all the pressure and sweaty armpits, i managed to do a good job.  we finished up the case and i helped close the ports as though i were an integral part of the case. 

this is all of what i look forward to.   i will miss it, as tomorrow is my last day.

as an update – today the same doctor asked, “if i let you do an entire vaginal hysterectomy, will you promise to come here for residency”.   fortunately, he doesn’t have any lined up tomorrow so i didn’t have to answer that question.  it’s nice to feel wanted.

Advertisements

step 2

Posted in medicine on October 27, 2008 by whenispark

well the score is in, and i managed a 262/99 which is flipping awesome.  another weight off my back.  and i am in the top 25% of my med school which is definitely also a bonus.  both of which will make matching a cinch.  wish me luck, i only have a bazillion interviews to do.

full of air

Posted in medicine on October 27, 2008 by whenispark

nothing makes a gynecologist’s heart drop faster than when they hear one of two things:

1. “why is the foley bag full of air?”

2. “the urine is red.”

those both mean one of two things – damage to the ureters or damage to the bladder.  despite their reputation of perf’ing plenty of these structures, it has been a rarity in my experience, albiet a limited one.  and by rarity, i mean it never happened in a case i have been in prior to today.  i was unfortunate enough to be in the case where the trocar (google it) went through both walls of the bladder. 

it was still something i needed to see – mostly because it’s a very possible complication when operating in that area, and because i was able to see a physician deliver bad news, something that can be particularly easy.  it was a fun morning though since i was the only one working the doctor – i got a lot of one-on-one attention.  the positive of this was negated by the fact that i only got 3 hours of sleep and said such idiotic things like:

“tomorrow’s game was bad news then…” – that was when refering to yesterday’s steeler’s game.   really?  tomorrow’s game was bad news? slick.

the condition known as msc

Posted in random rants on October 9, 2008 by whenispark

also known as “medical student castration”.  it’s the position you are put in by the fact that you are not allowed to place orders and no one generally cares what you think.  if you’re lucky, you might be able to express your own opinion – that’s assuming you agree with everyone else.

you might be wondering where this newfound bitterness stems from – and it certainly is newfound.  it’s primarily from my chief resident right now.  as an m4, i no longer answer to an intern.  in fact, i don’t even see them.  this is a pretty major change from m3 year where the lower-level residents were the only ones you had contact with. 

here’s the problem:  we have a patient with a history of chronic pain who is on medications A, B, and C.  she had her surgery to rid her of one of her origins of pain – a retroperitoneal cyst.  there is no guarantee that this has been causing her pelvic pain, but it seems likely.  she had an exploratory laparotomy (the opened her up, unlike laparoscopy where they put in little holes), and we probed around in her bowel, took stuff out, sewed her back up.  regardless of her history, this is a procedure that inevitably will cause the patient pain, pain, pain.   any other patient with this surgery would be getting plenty of pain medication.  the situation become sticky because she is already on pain medication – which means, she needs MORE.  even though we have fixed a potential source of her pain, she’s still going to have pain just from the surgery.  so what do we do?  we give her medication A and B, and a mere fraction of what she normally gets of C.  this will inevitably amount to inadequate pain control.  so inadequate that i walked into her room with her hunched over crying in pain.  i tell my resident and what does he do?  brushes me off.  and therein lies the castration.  here is a patient in a lot of pain, and i can’t do anything to help her.  it’s keeping her up through the night, and she has no appetite.  but wait! there’s more!

she quit smoking about 3 days ago, and for those of you quitters out there, you might recall that counterintuitively, after you quit you have an increase in mucous production.  at face value it doesn’t make sense, but, when you realize that smoking paralyzes the cilia of the lung cells which move the mucous out, you would know that the mucous then accumulates.  when you stop smoking, those cells egt back into action, but now they have lots of catching up to do!  so lots of coughing up mucous.  this is her next situation, except guess what!  when you cough, you increase your intrabdominal pressure, which hurts alot when you just had an invasive surgery down there. 

so then i ask him if we can either give her a breathing treatment or something to help her with this mucous to loosen it up.  i don’t want to give an expectorant because then she’ll cough more and with her pain not controlled i hardly would want her to go through that.  and a suppressant doesn’t make much sense because it’s not a dry cough – we need that stuff out.  well he refuses the suggestion of a breathing treatment (in addition to any change to her pain medications), but finally after much nagging he does give a crappy suppressant.  hey hopefully at some placebo effect contributes.

so what’s a student to do.  like i said, i can’t order anything.  i can’t call the attending because i can’t go over my resident’s head, but here i am concerned about my patient who is entirely dissatisfied with her care (a large part due to her pain) and no one can explain to her what’s going on, least of all me because i’m definitely left out of the loop.  it would be one thing if i was doing this for some ulterior motive (although i can’t even fathom what one might be), but really i just want to help the patient and to learn how to take better care of them.  this isn’t a battle for who is right.  i just want the damn patient to be happy and as comfortable as possible after her surgery. 

fortunately, the patient asked if she should call her doctor, and i said, as a private patient, you are absolutely entitled to discuss your care with your doctor.  i wouldn’t have even said that if it weren’t for the advice of another resident i frequently turn to for advice. 

i guess ultimately it is just extremely frustrating when every effort you make to help a patient is not percieved as such.  he honestly just gets irritated when i make suggestions without explaining why not.  so really, what is a medical student to do?

 

i also should note that this same resident tells me NOT to write down what physical findings i find on a patient.  i am literally NOT allowed to write tender to palpation.  i have to check with him.  as though i can’t assess when it hurts to palpate an abdomen.  i am also NOT allowed to write down what MY assessment and plan is.  so really – why am i even writing a note.

honestly, i think tomorrow i’m going to talk to my favorite attending, because i am at my wits ends.  i have never been so stressed out about this kind of stuff.  fortunately, i have been able to hide it all and i’m nice as ever to the resident.  i’m more concerned about the other student who will be working with him in a matter of 4-5 days.  oh well – i will try to prep her before she starts.

ob/gyn at my home base commences

Posted in Uncategorized on October 8, 2008 by whenispark

it’s pretty great to be back – free food, free parking, attendings and residents that i already know.  i only anticipate the time spent to improve. 

this first week has been gyne service, and while i skip the silly details, i am obliged to say that the chief i work with has been strangle-worthy lately.  overall, he’s a pretty decent guy – i know he just wants to make me a great student and prepare me for residency.  but sometimes he just says and does ridiculous things.  such things include telling me that he thinks i am a good student, but that some people in the program are still unsure of me.  this comment may be entirely true – and that’s fine.  but there is no point in telling me this.  although i do doubt that it is true.  time and time again, i am able to impress attendings with both my knowledge and skills when put to the test.  i can do a mean subcuticular stich along with a quick and neat suturing of the fascia.  this program is good, but it’s not the best on the list, and i know many of the attendings and residents are hoping i will come there.  i know i can get into better programs, and i might really go for those better programs – so telling me that some people are all “meh” about me is not really a way to sell a program to me.  i’m a good candidate and i will definitely bust my ass on residency.  even as a fourth year i work more hours than i need to – and it’s not to impress them – i don’t need any letters of rec – i already got ’em.  whatever.

anyway, i’m looking forward to friday.  i will be done with that resident, i’ll pick up some pictures, and head back out to the burgh for some fun.  plus, on friday, i’ll get to scrub in on some surgeries where i might actually be the one doing something instead of watching.  we will see.   i have to go though, nasal congestion is making me sleepy and i still want to go for a run on a miserably gray october evening.

3:47 am

Posted in tangential/circumferential on October 2, 2008 by whenispark

that time simplifies one of the fantastic aspects of the fourth year of medical school which is that you have no tests (once you have completed usmle step 2) and minimal obligations on rotations.  this is something that blew my mind when i was a newly entering m1.  i could not believe that fourth year was essentially a joy ride with much of the time when you’re supposed to be on rotations, you are off interviewing. 

i have been further blessed by the fact that my next elective doesn’t start until the 6th of october, and i finished my last rotation on 9/19 and step 2 on 9/30.  i am home free for those 6 days in between my test and my next rotation.  well, not entirely.  since i have been in pittsburgh for the past month, i have a lot to catch up on.  like bills.  oops.  i actually got a call today from summa regarding one of them.  they can wait.  i think it’s only 100 dollars.  100 i would rather not spend there, but clearly there is not a component of choice.  additionally, i have had multiple meetings and other errands i have neglected until this time.  unfortunately, there are just not enough hours in the day. which has resulted me being up until 4 in the morning. 

overall, this has really been an exciting time for me.  i have submitted my eras (electronic residency application s…something) to 22 programs.  i have changed my mind on 2 of the programs and 1other program is for a “practice” interview. so, out of the 20 programs i will interview at, i already have 9 interviews.  this is going to be a little overwhelming… i was originally saying i would only do 6 or 7 interviews, but now i know i’ll be doing more.  i can’t do 20 interviews if i somehow manage to get an offer at all of them (which i don’t anticipate), but i don’t even want to do much more than 10.  it’s nice having too many options 🙂

so that’s pretty much it in terms of life update.  i’ll have some other posts in the days to come (if not in the days to come, then definitely starting october 6th…i’ll be back in pittsburgh this weekend).