Sunday, February 27, 2011

2 weeks and counting

2 weeks from tomorrow I find out if I matched or not and then on March 17th we find out where we are going. We are hoping it is out west somewhere. The girls would all like to live a lot closer to Granparents. We hope it works out that way. I thought they would be sad about leaving our house here in Columbus but I think it will be a pretty smooth transition. Its crazy to think that I will be graduating in June and will actually be expected to know stuff. I'm looking forward to moving on and actually getting paid to work. I will be doing general surgery residency which will last for the next 5-6 years depending on where we go. No more having every holiday off and I wont get a three month breaks from school anymore. At age 30 I guess its time to enter the workforce.

Palliative medicine

A few months ago I was on a Pain and Palliative care rotation. Honestly I took that rotation because I have already become too skeptical of pain. Sometimes I feel that in the hospital and especially the er we treat patients that come in with pain as drug seekers until proven otherwise. While there is a fair amount of that going on and such people for the most part are easy to spot, there is another population who cannot have any meaningful quality of life without regular doses or Dilaudid, morphine, OxyContin, Percocet, and other narcotics. I took the rotation to learn how to exercise proper relief of pain especially since I am going into surgery and will be inflicting varying degrees of it on my patients. I got a lot more from that rotation than I bargained for.

Palliative medicine is about providing comfort and increasing quality of life for people facing the end of their mortal existence. Doctors in the field routinely have some of the most difficult discussion that patients are confronted with: 'what do you hope to accomplish with your remaining time' 'how do you want to spend the time you have left?' ' do you want us to perform CPR in the event that your heart stops?' Do you want us to put a tube in you and hook you up to a machine if you can't breath on your own?' ' do you want to be at home, a facility or a hospital' these are just some of the questions that may get asked. I have seen multiple patients with stage 4 cancer who have had it for months and have very little time left. Surprisingly, most of the patients have no formal documents in place to express their wishes in the event they are incapacitated.

Most people envision themselves dying at home, comfortable and surrounded by loved ones. The reality is most americans die in hospitals with a good number of those surrounded by staff sticking them with lines, filling them with fluids and meds, breathing for them with a mask, shocking them with paddles with a med student pumping on their chest. ON TV the patient seems to make it 90% of the time. In reality only 15% of otherwise healthy patients survive and half of those will have lasting effects. Survival drops practically to 0% in patients with end stage cancer, heart failure or other terminal conditions.

I have seen people die a few times as a med student. I have been a part of resuscitative efforts, compressing someone’s chest and trying to not drip sweat on them after the fifth round of two hundred chest compressions, feeling ribs crunch and break under the weight of my hands as I try to pump their heart at 100 beats per minute to the tune of 'staying alive' or "another one bites the dust", my arms burning with fatigue and watching the monitor to make sure my compressions register. Occasionally the attending will ask me if I think the EKG rhythm is shockable or which drug should be pushed next. (it will be expected of me to run a code by myself in a few months when i graduate) Ultimately an attending decides that the physical efforts are futile and calls the time of death. The patient was likely gone long before that. I remember staring into the half open eyes of one of these patients and thinking there was nothing there. Contrast that with another experience I say at an inpatient hospice center: the patient expires peacefully in a quiet environment with their loved ones nearby.

Death is a process. From a medical stand point it takes a while for body systems to shut down. Many of the cellular processes continue for hours after that. In the active phase of dying the heart rate and respiratory rate increases. The temperature can rise. Patients can switch from restless to sleeping in minutes. Ultimately the breathing becomes sporadic. The blood pressure drops and the patient becomes obtunded as there is not enough circulation to keep the brain going. The process can take minutes to hours in the final stages. Some of the docs and nurses have commented to me that the patient actually looks smaller when they die as if a part of them has left.

The doctors I worked with help to make this transition as peaceful as possible, providing pain meds to help with breathing discomfort, drugs to help dry up throat secretions so the patient doesn't choke, and sedatives to help with agitation or restlessness. The meds do not speed up the process of dying. These patients can be at home and have their families around them.

The word hospice in our culture has had a negative connotation. I think many people feel that hospice is 'giving up.'? I definitely don't see it that way. I see it as a dignified way to have a little control over our last moments of mortality.

Aquarium update one year later

Gold Angelfish - had to treat this guy with flagyl for about 2 weeks when I first got him but hes been doing great for about a year now. He's the showcase fish.

Cardinal Tetra - Still have three of these guys left. Had 'em for over a year which I think is about their expected lifespan. This is one of my favorites except they are super boring and just hang out in the plants at the bottom of the tank. Maybe because the angelfish is their natural predator in the wild? No problems for now.

Siamese Algae Eater - still working hard.

Bosemani Rainbows - These are great active fish. The have definately established a pecking order in the tank. They chase each other mercilessly in the morning but don't seem to do any damage.

Sunday, March 7, 2010

Aquarium Update

Here are some of the latest additions to my obsession/hobby:

The tank is a 37 gallon tank with 110 watts of light at 6700K from a homemade fixture. It's CO2 injected with a paintball cylinder, regulator and pH monitor. The plants are Anubias nana and barteri, some green crypts, java moss, baby tears, purple cacomba, dwarf hairgrass, amazon swords and red leaf ludwigia. I'm still working on cultivating the plants and adding more to the tank. I regularly dose fertilizers (nitrate, potassium, phosphate, CSM+B) and maintain the tank at pH of 6.8 with 6 degrees of KH.

Bosemani Rainbow. The male is more brightly colored than the female. I have a juvenile male that is kind of intermediate between these two color wise but he is kind of shy with this dominant male around

Kribensis dwarf cichlid (complete with a nice string of poop)/ I tried to get rid of this fish because it seems a bit territorial but I was never able to catch it so its just chillin for now. I can't believe how fast it is when it wants to be. It seems to just putt around the tank very slowly most of the time. It took out most of my juvenile shrimp and also seems to snack on young Ramshorn snails.

TRUE siamese algae eater. This fish earns its keep. It eats hair algae like there's no tomorrow. I highly recommend this fish for a planted tank but make sure it is not a false siamensis or a flying fox. Do your homework so you know what to get. It seems to be a bit territorial around chow time with my Cory's which is atypical for this species but it hasn't done any harm so I think its just trying to be social. I purchased it when it was about 2 inches long and it has at least doubled in size. The girls call this one 'the Mommy fish' because its the biggest one in the tank right now.

Corydoras sterbai. I really like this fish and it's a great scavenger of leftover food. They get harassed by my SAE and the Kribensis but so far no major problems. It kind of reminds me of a mouse and occasionally rolls its eyes which makes it look like it's winking. This female occasionally lays eggs but none have ever been fertilized. I have a pair of these and it is pretty much the only fish I have left from my original setup. (See below) I lost some of my fish to infection and traded in a lot of the originals. Since I added a sterilizer, I have not had any problems with fish loss unless they were in poor shape on arrival.

Cardinal Tetra. I have about four of these left over from my attempt to acclimate a small school to my tank. Its hard to find a well handled group from the local fish stores but they make a great addition once they survive. They get a little bigger than Neon tetras and are much more colorful.

Olive Nerite snail. I had a horrible time with brown and green algae on my driftwood and plants and finally discovered these guys on eBay. I bought 5 and they cleared my whole tank of algae in about a month. They also clean my filter intakes and heaters. The only drawback is that they lay little white eggs everywhere. (white dots on the snail itself and see the driftwood pic above) They can't hatch in freshwater but they are a nuisance and attach tightly to everything, including other snails. I'm hoping the egg laying will slow down in a few months but for now I can put up with these better than algae.

Saturday, March 6, 2010

Pediatric Surgery

I finished up Psychiatry and Neurology last month and moved on to 'The Big One' : my surgery rotation. I am currently on the pediatric surgery rotation at Nationwide Children's hospital and am loving every minute of it. I have seen a lot of really cool things this week. Yesterday I spent about 12 hours in the OR and then took call overnight and got to scrub into an emergent perforated duodenal ulcer repair. I have seen repairs for kids whose insides were on their outsides because their abdominal walls didn't form correctly (Gastoschisis), bowel resections, splenectomies, skin grafting, appendectomies, incision and drainage of abcsesses, feeding tube placements and takedowns and a variety of other procedures. Surgery at the student level consists of a lot of retracting, cutting and tying off sutures which may seem pretty menial to most of the other students but I love every minute of it.

Last night we were performing an exploratory laparotomy, which is just a large open midline incision and exploration of the abdominal cavity and organs, on a poor little kid who was pretty sick. The kid's CT showed free air in the abdomen which is a sign that there is a hole in the GI tract somewhere. This can be a life threatening condition so we operated in the middle of the night. The surgeon's found and patched a perforated ulcer in the patient's duodenum. At one point the surgeon asked me to stick my left hand inside the abdomen and check for adhesions around the liver and asked me if I felt anything. It was nice and smooth. "You're a surgeon now." he joked.

The surgeons at Children's are great. They are all very friendly, remember my name and try to teach me new things even at 4:00am when I'm sure they would rather just hurry as fast as they can and go back to bed. The patients are great, too. We have operated on kids from 6 months to 20 years old so far.

I think the most incredible thing about pediatric surgery is the hope that these people can provide to these patients and their families. I can imagine nothing more nerve racking or devastating than finding out that your child has a major birth defect or has been severely injured and needs a major operation. Wonderful advancements in surgical technology have turned potentially catastrophic problems into manageable conditions, many of which have very good outcomes.

Pediatric surgery is a 2 year fellowship which is completed after a 5-6 year general surgery fellowship. It is extremely competitive to get into and most fellows have taken time off for research. Essentially, most fellows have around 10 years of training after medical school by the time they are done with pediatric surgery training.

Update: At this point I am planning my 4th year courses to prepare to apply to General Surgery residency. I will blog more about my decision in a little while.

Thursday, October 22, 2009

Baby Catching

This Last month I have been on my OB-GYN rotation at St. Anne's hospital in Columbus. I know what you are thinking: "So how did THAT go?"

Actually I liked it quite a bit. I got to participate in a lot of neat surgery, procedures, and deliveries.

My first night on call I met a couple in Labor and Delivery getting ready to push out the latest addition to their family. I introduced myself as a 3rd year medical student and they asked me if I had caught any babies yet. I replied I hadn't and much to my surprise they asked me if I wanted to catch theirs. "You gotta start somewhere." they said. I was honored to start with their baby. (I didn't drop her either.) Mom and baby did great.

Catching babies is warm, wet, slippery, cheesy, bloody and awesome. Cesarean sections are essentially the same but with more sharp things. It is probably one of the bloodiest surgeries I have seen so far. I now have mad skills when it comes to bladder retraction, cutting suture strands, suctioning smoke from the cautery device and amniotic fluid, and stapling abdomens back together. (The few things they actually let a med student do. Sigh)I did get to be the first assistant in a few cases which was great.

Gyn surgery is very interesting also. I saw abdominal, vaginal and laparoscopic hysterectomies, cyst and fibroid removals, tubal ligations, D&C's (nope its not just a book of scripture) and hysteroscopy. One of the more interesting surgeries that I saw was a laparoscopic fibroid removal. Fibroids are basically benign tumors consisting of smooth muscle cells and fibrous connective tissue. They tend to be found in the uterine wall. They are the most common reason for hysterectomy but in some situations a woman may opt for a myomectomy, removal of the fibroid from the uterine wall, rather than a full on hysterectomy. This is possible because fibroids are well encapsualted and can usually be pulled out in one big round chunky yellow mass. It is extremely satisfying when they yank one out -kind of like the feeling you get after you pop a nice ripe zit. Gross I know, but that's the only way I can describe it.

There is a lot about this specialty I really like: a good percentage of the patients are young and healthy, there is a good mix of surgery and clinic, you have to be well rounded as an OB-GYN can sometimes be the only doc that some of these patients see. This is the only specialty where people come to the hospital for a happy reason and its only av4 year residency program. I also felt like I got along well with the residents and attending physicians. I was much more comfortable around them than some of the other surgeons I have shadowed. Another interesting thing is that 80% of the applicants to OB-GYN are now female and males are in high demand. A male applicant with good grades and board scores can potentially go wherever he wants.

The subject material of OB-GYN can be very sensitive most if not all of the time but I found that I really enjoyed talking to and interacting with patients in this setting. As long as one can be empathetic and understanding, I have heard that most women don't care if they have a male or a female for their OB-GYN.