Ah the good old days!!!

I wish we could go back to the good old days when this country was first founded and hold our elections like the first ones when the runner up became the VP. Washington/Adams, Adams/Jefferson. Wouldn't that be awesome? Just picture it...Obama/Palin or Palin/Obama! Oh wait... whats that you say? John McCain is running for president?

Take the Summer challenge

Happy Anniversary Honey!
The Summer Quiz

1. Summer’s favorite color is:
a.Pumpernickel
b.Fuscia
c.Periwinkle
d.Clear

2.Which of the following are among Summer’s least favorite foods?
a.Bananas
b.Pasta
c.Fish
d.Chocolate
e.a and c

3. Summer’s talents include
a. Blogging
b. Singing
c. Photography
d. Digital retouching
e. Digital scrapbooking
f. Baby juggling
g. Drawing
h. All of the above

4. Summer’s husband is
a. Tall dark and handsome
b. Slightly shorter and younger but still handsome
c. A lizard

5. What complete series of teeny bopper books does Summer have stashed in her closet:
a. The Hardy Boys
b. The Babysitter’s Club
c. Goosebumps
d. Bram Stoker’s “My Little Pony” series

6. What language(s) does Summer speak?
a. Italian
b. English
c. Cebuano
d. Hindi
e. a and b

7. How many Gigabytes worth of pictures that she has taken does Summer have stored on her hardrive?
a. 20 GB
b. 40GB
c. 100GB
d. 160GB

8. How much money did summer win in a sales competition when she worked at 1-800-contacts?
a. $200
b. $4000
c. $50
d. $999
e. $500

9. Which of the following fast food joints did Summer work at as a teenager?
a. Goliath burger (Sandy mall)
b. The Hungry Mosquito
c. Hot dog on a stick
d. Big B’s
e. The Chum Bucket
f. a,c,d
g. a,d
h. b,e

10. What Disney Princess is Summer most like:
a. Ariel
b. Pocahontas
c. Mulan
d. Belle
e. Aurora

11. Summer has a very cute birthmark at the base of which toe of her right foot?
a. The big one
b. Number 2
c. Number 3
d. Number 4
e. The Pinky

12. True/False Summer has free hanging earlobes?

13. Summer’s favorite animals include:
a. Bunnies
b. Minks
c. Wolverines
d. Cats
e. NOT dogs!!!!
f. a, c, d,
g. a,d,e

14. What beverage does Summer have with every meal?
a. Apple martini
b. Baby formula
c. Skim milk
d. Kool-aid
e. Water
f. Fire water

15. What is missing from Summer’s arms?
a. Elbows
b. A baby
c. Any hair whatsoever
d. The ‘Gun’ show

16. How many blankets does Summer sleep with no matter what time of year?
a. None
b. 3
c. A billion

17. What does Summer call her shoulder blade?
a. The thingy
b. The scapula
c. Her chicken bone
d. Ouch

18. Summer has perfect eyebrows.

19. What did Summer lose down the shower drain in Sicily
a. Her Book of Mormon
b. A 14 karat gold CTR ring
c. Soapy water
d. A shoe
e. b and c
f. All of the above

20. How many pieces are there to Summer’s wedding ring (which she still has all of)?
a. What ring? Zach is a cheapskate
b. 2
c. 3
d. 4

21. What car did Summer used to drive?
a. A VW beetle
b. Dodge Neon
c. A Gremlin
d. A Smart Car

22. What is Summer’s favorite musical?
a. The Phantom of The Opera
b. West Side Story
c. 7 Brides for Seven Brothers
d. The Scarlett Pimpernel

23. What is the best thing about Summer?
a. Very Funny
b. Incredible writer
c. Wonderful Mother
d. Super Intelligent
e. Makes everything she does beautiful
f. She is a knockout
g. All of the above

Answers

1. D
2. E (They do sound gross together)
3. H
4. B (C is not correct but good try)
5. B (and I mean all of them)
6. E
7. E
8. B
9. G
10. B (That one is in her blog on Friday July 11th)
11. D
12. True
13. G
14. C
15. C
16. B
17. C (I will also take D)
18. True
19. E
20. D (It came like that)
21. B
22. B
23. G

Bugs N' Drugs

I'm back in school already. (Feels like I never left) I'm starting out the year with microbiology, which covers all of the nasty little viruses, bacteria, parasites which can cause us a lot of misery. I have been a little nervous about this part of my studies because I have to learn dozens of names like Erysipelothrix rhysiopathiae, and Nocardia cyriacigeorgia, how they are transmitted, how they make us sick, and how to kill the little buggers. I'm starting to compile a list of bug caused diseases that I never want to get. Here goes...

Bacillus anthracis - commonly called known as anthrax. This critter lives in the soil and can be found hanging out on sheep or other livestock but is infamous for the spores which have been created biological weapons. Once inhaled the spores can reside in the lungs for up to two months without causing disease. The body has cells called macrophages which ingest the spores and transport them to lymph nodes so our immune system can destroy them but when they get there these critters begin to grow and divide. They secrete toxins which travel throughout the blood stream which causes fluid and blood to leak out of the vessels. The patient starts to bleed out of their bodily orifices and can die within 72 hours after inhalation if treatment isn't administered. Luckily, common antibiotics can treat this infection if caught early enough. This was the stuff that was sent through the mail a couple of years ago.

Ebola Virus - Ever seen the movie 'Outbreak'?

H5N1 - this is the serotype for Avian influenza (Bird flu). It can't go from human to human yet but has a very high mortality rate in people infected from chickens. This is the one that has gotten so much attention in asian fowl over the last few years. The crappy thing about this virus is that it is more dangerous to younger people that to other population groups. It causes a hyperactive response of the immune system and therefore younger people with a strong immune system are a lot worse off with this disease. Many experts agree that it is not a matter of if it becomes transmissable from human to human but when. A small minority believe that if it was going to happen it would have already.

HPV - Human Papilloma Virus. This critter is pretty common. Certain types cause cervical cancer and are the target of the new HPV vaccine Gardasil. Some types can cause common warts. No big deal right? Not if you have a very rare defect with your immune system. Just do a goolge image search for Tree Man of Java.

The last on my short list is: Streptococcus pyogenes (Group A strep). This one may sound familiar. It is responsible for strep throat, scarlet fever and rheumatic fever. While those range from serious annoyance to debilitating, the thing that I fear the most from this bug is, drum roll please, necrotizing fasciitis. For some reason, introduction of this critter through the skin can cause an infection capable of reducing skin, muscle, fat and connective tissue into goo within hours. One of my favorite books, 'Complications' by Atul Gawande, cites a case where a young woman got it in her leg from dancing on a lawn at a wedding. It result from penetrating wounds or surgery. The only cure is "surgical debrigdgement" of damaged tissue. (ie remove it surgically) The bacteria also secrete toxins into the blood stream and the patient can die within days of receiving the infection. Many of the survivors are left with horrible scars. WARNING! Only google image search this one if you have a strong stomach. (yes, I dare you!)

I am also learning about the drugs to take out these nasties. Unfortunately, overuse of antibiotics is making many diseases hard to treat. Bacteria can mutate and become resistant to antibiotics if they are not used carfully. So I'll stand up on my soap box and encourage everyone to finish every last pill of their antibiotics prescriptions when prescribed and dont ask for a prescription if the doctor says you dont need it. (ie. you have a virus instead of a bacterial infection)

My summer research

Just thought that I would take a minute to update y'all on what I have been doing this summer. I have been working in the Center for Gene Therapy at Nationwide Children's Hospital in Columbus. I received a scholarship from the medical school to help with living expenses. The research we are doing is really interesting. The short of it is that we are working on a treatment that would help rebuild muscle in patients who have muscle wasting diseases like Duchenne Muscular Dystrophy. There is a protein called follistatin which has been shown to increase muscle fiber size and function. Follistatin inhibits another protein called myostatin which limits muscle size. There are some interesting things that happen when you take out myostatin. The pictures below are of animals which have a defect in the myostatin gene. The dog is a whippet greyhound... yeah the fast really skinny tpe. This is called double muscling and recenlty this myostatin defect (if you could call it that) has recenlty been identified in a four year old boy. In our lab, We use a virus to deliver DNA to muscle cells. The DNA codes for follistatin which causes the muscle cells to produce extra follistatin and inhibit myostatin. We have gotten some pretty ripped mice and monkeys with this therapy and everything is looking really good so far. They want to start clinical trials on humans in about a year and I am helping my lab look at the immune response to gene delivery in monkeys.

I love pigs feet!

I've eaten my share but they are much more enjoyable for practicing suturing due to their similarity to human skin. I recently purchased a book called Essential Surgical Skills. It basically contains all of the stuff they don't teach you in medical school but are expected to know during your surgical rotations. It includes a lot about suturing and skin flaps. Skin flaps are used to correct a defect in the skin either due to surgical removal of a lesion or from injury. It basically consists of moving a piece of skin from one area to another. The elasticity of the skin makes it possible to do this without creating another gaping hole. Another important factor are tension lines. Making the final scar parallel to these tension lines reduces the scarring and gives the most favorable outcome.

In my spare time I have been practicing a little bit, and completed my first couple of skin flaps. Who knows how well they worked. Dead pig feet don't heal well. I think I caught a glimpse of what some surgeons must fell when they operate. After the initial excision there is kind of this "Oh crap, how am I going to put this back together feeling." As you start placing stitches, it starts to come back together until eventually the gaping hole is closed over. The final product is extremely satisfying, even on a pig's foot. I can see why people want to go into plastic surgery. That and the hours are better. And there is something very artistic about it.

The best part about all of this is that all the suturing materials are sterile and you can eat the pigs feet afterwards. If you like eating thick hairy skin and gigantic toenail.

On Call part 2

On friday I went to shadow some of the residents on call at the hospital for the second time. I learned some very important lessons that night. The first case that I got to see was the tail end (no pun intended) of a colon and rectum resection (Lower Anterior Resection is the technical term). The patient was an older gentleman who had colon cancer. The procedure was very interesting to watch. They had removed about 1.5 feet of his colon including his rectum all the way down to just above what is called the pectinate line (the sphincter region of the anus.) They then reattached what was left of his colon at this point. The surgeons had run into a few problems and the procedure lasted about 10 hours. This was a very interesting followup to the colonoscopy that I saw a couple of weeks ago. This is what happens when you don't detect colon cancer early and man it was not pretty. I wished that I could pictures of the procedure and make a poster to encourage people to get colonoscopies after the age of 50. Anyway, I won't provide any more details.



The surgeon was a colorectal surgeon who had recently came to OSU. He was a great guy. He had been up since 2:00am that morning, started the colon resection at 9:30am and finished at 8:00 pm. Even after working so long, he was very nice to talk to. I asked him and the resident the question that has been burning in my mind: "Why colorectal surgery?" They both responded that they have really enjoyed the interactions they have had with colorectal surgeons. They tend to be very friendly, and have a great sense of humor. They also enjoy the procedures which I will say the one I saw was very interesting. It seemed almost impossible to accomplish what they did.



I also got to go down to the emergency department with another resident. They had a car crash victim that they were evaluating and while we were there a gunshot victim also came in. He had been found wandering aroud with two bullet holes in his leg. There were both entry and exit wounds. The patient was quite intoxicated and pretty difficult to work with. Tensions seemed to be running high between the ER staff, the surgical staff and the radiology crew. It reminded me a lot of volunteering at the Utah Valley Regional Medical Center emergency deptartment and why I am not at all interested in doing emergency medicine. I was extremely impressed with the surgical resident's ability to control the situation and evaluate the surgical needs of the patient. It basically amounts to controlling chaos.

Drawing lessons from an almost 3 year old

This morning I was coloring with Mia. I figured that she is probably coordinated enough to start learning how to color in the lines a little bit. I tried to show her how to do it. After watching me for a few seconds she grabbed the crayon out of my hands and said: "No Daddy! that's not pretty enough." She then proceeded to instruct me in the art of scribbling. She knows what she is doing.

New Look

I have to thank my wife for the new look. You would never guess that I am still a novice blogger with a layout like this one. She asked me if it was too girly. I told her that I would just have to write a blog explaining the new look as most guys probably wouldn't be able to come up with something so decorative. She is particularly proud (as am I) about the drop shadow under the stethoscope. It looks very life-like. The picture is of the girls locking me out of the house. The door only opens toward them so I had to go around to the front. I wish I had a camera shot from my angle. Oh, and I finally picked a name for my blog. It goes well with the picture so it will stick.

On call

This last Thursday I went to shadow one of my instructors, Dr. S, at OSU. He is my learning society mentor and a general surgeon who specializes in burn, trauma, and critical care. He is also one of the main faculty for the residents and somehow finds time to interact with 1st year med students. It was a pretty eventful evening. I arrived rather rushed at 3:45pm to his office. We were supposed to attend a morbidity and mortality conference. He wasn’t in his office, as “on call” surgeons usually aren’t and his secretary wasn’t expecting me. He had forgotten to tell her I was coming and she was a little annoyed. It must be hard working for a surgeon when you can’t handle unexpected changes to your schedule. She looked him up for me though and told me how to find to him. He was beginning a case in one of the ORs, on the 4th floor of the hospital. I caught him just as he made his way in to the surgical area. He seemed a little surprised to see me also and had probably forgot I was coming.


The first case was an elderly gentleman who had come in with a horrible case of acute cholecystits (gallbladder attack). He had been having pain for a few days and only recently came to the hospital. Dr. S performed the procedure laparoscopically with his 4th year resident. At first I thought, “O great another cholecystectomy. This was supposed to be on call trauma, wasn’t there anything more exciting than this?” I have seen videos and another live gallbladder operation previously but this one turned out to be a good experience. I was the only medical student in the room and had a clear view of the patient and the TV’s.


They made a small incision just above the navel and began to insert the first port. (Ports are plastic tube-like anchors which are stitched into the flesh and allow the passing of the laparoscopic instruments into the abdomen. They are removed after the operation.) The inserted some suture on either side of the incision and tie the port into the abdomen with the remainder of the long strands. This port is the insertion point for the camera. The camera is inserted and the abdomen is inflated with carbon dioxide gas. It slides into the peritoneal cavity underneath the abdominal muscles and you get your first view of the organs inside. The liver is easily noticeable and the intestines are covered in a fat laden apron called the mesentery. The patient’s gall bladder was easily noticeable as it protruded its way out from underneath the liver. It was grossly swollen and looked about ready to pop. Apparently the duct that allows bile to leave the gallbladder was blocked. The nearby tissue was also very swollen and glistening.



The next step is to insert 3 additional ports into the abdomen: one just to the left of the midline near the base of the ribcage, and two on the right side of the abdomen also near the ribs. Surgical tools are inserted into these ports which allow the Surgeon to inspect, dissect, cauterize, clamp vessels and remove the damaged gallbladder. Dr. S had to remove about 20 mL’s of bile from the gallbladder with a needle and syringe before he could get a good enough grip on it to proceed. The next step is to locate, clamp and cut the cystic duct which conveys bile to the intestine and the cystic artery which is the blood supply to the gallbladder. They are clamped with small metal clamps which remain in the patient. Once the vessels are clamped, the gallbladder must be cut away from the tissue attaching it to the underside of the liver. They use an electrocautery device to burn through this loose tissue and cauterize and small blood vessels along the way. The gall bladder is then placed in a tough plastic bag and pulled out through the large port hole near the belly button. They had to make that incision a bit larger to get this patient’s gallbladder out. They final step consists of irrigating the abdomen and rinsing out any bile or tissue which may have leaked. The abdomen is then deflated, the ports are removed and the incisions are stitched. The whole procedure lasted about 40 minutes.


After the surgery we went to round (check up on/evaluate) on a few patients. The 1st was an elderly woman in the surgical intensive care unit with a bad case of pneumonia. She had recently had multiple antibiotic resistant infections and was in contact isolation (that means you have to wear gloves and a gown to even enter the room). The pH of her blood had become increasingly acidic and the doctors were worried that maybe a section of her bowel had become necrotic (died). Dr. S recommended to the staff that an endoscopic examination of her bowel be performed.

The 4th year resident from earlier and I came back a little later and she performed the “scope.” This was not the highlight of my night. I don’t know that there is anything enjoyable about this experience from the perspective of the patient or the doctor, especially in someone whose bowels had not been thoroughly evacuated prior to the procedure as is common in a screening checkup with a gastroenterologist The scope didn’t show a lot. The resident couldn’t get past the sigmoid colon just beyond the rectum because the patient was in too much pain. Normally they would probably sedate the patient but this patient refused to be "tubed" (intubated) so they had to perform the procedure with only pain meds. The patient was in a lot of pain and probably pretty embarrassed from the whole ordeal. When all was said and done, the “scope” turned up nothing.

The last patient I saw was a younger woman in her thirties. She had come to the hospital with extreme abdominal pain and constipation. Dr. S visited her with a panel of surgical residents and myself tagging along. The patient had gastric bypass (GB) surgery previously and lost about 115 pounds over the course of a year. Dr. S explained that it was not uncommon for patients with such dramatic weight loss from GB to have problems with their intestines becoming intertwined or stuck to scar tissue from the previous surgery. A CT taken earlier of her bowel suggested that it was partially obstructed. Dr. S called one of the surgeons that specialized in GB and asked him what he thought. This surgeon recommended exploratory surgery of the abdomen. He mentioned that 9 times out of 10 typically he had found a problem in patients who had previously undergone GB. The 4th year resident and I came back a little while after the initial visit to tell her what the recommendations were and to get consent for the surgery. The patient wanted to know how large the incision would be. The resident explained that they could go in through her previous midline incision and it might not have to be as large. The patient mentioned that she didn’t have insurance and the resident reassured her that was not the most important thing to worry about at the moment.

After we got the consent form and left the room I asked the resident if it were possible to perform the procedure laparoscopically. She said yes and it would probably take a very experienced surgeon. The importance of this is in the recovery. Laparoscopic procedures yield much faster recovery times that open procedures and have a smaller risk of infection. Our patient would have the open procedure. Maybe it had something to do with the fact that her GB was also performed "open."It seemed unjust to me that the laparoscopic procedure is available and yet it wasn't even considered in this case. One of my professors back at BYU had to have an abdominal exploration for a very similar condition and the were able to execute it laparoscopically. In this patient's case it would cut the recovery time in half. I am not an expert and don't have any idea about the rationale behind the open vs. laparoscopic procedure in this case but I can't help but feel that it may have had something to do with the training level of the residents who would perform the surgery.


After this consult, we had some down time. I got to talk to the resident a lot about surgical residency and what her plans were. She gave me some insight into fellowships and about what to expect. She is married and has two young kids of her own. It seemed like when I brought up the fact that I had three of my own she lightened up a bit and really started talking. Of course that could have been because we finally had gotten some food and were able to sit down for a second. I asked her why she had chosen surgery. Everything she said seems right in line with what I want in a specialty and reconfirmed my impressions about general surgery. (I am trying to be objective about my future career but I keep coming back to this specialty)


After dinner, we headed back to the OR. It was about 8:30 at night. The patient had been prepped and two residents were ready to begin. They had paged Dr. S and he was on his way. The residents made a large midline incision down the initial scar and then opened up the muscle and fascia with electrocautery. They pulled out a small loop of intestine and began to follow it along. It looked a lot thicker, redder and softer than what I have seen in cadavers. It also seemed endless as they kept pulling more and more out. The small intestine can be up to 21 feet long! When Dr. S arrived he insisted that they lengthen the incision so they could get a look at things as they were supposed to fit inside the abdomen. Prior to this, the residents had heaped most of the small intestine externally onto the patient’s abdomen. The incision now extended from just below the breastbone to just below the navel. They followed the whole length of intestine along from the stomach to the colon. Nothing seemed abnormal or out of place. They placed the intestine back where it belonged, stitched up the muscle and fascia with thick suture and then closed the skin with a line of staples. The procedure took about 40 minutes also and was conducted entirely by the residents. Dr. S didn’t even need to scrub in. He supervised the surgery from over the shoulder of the residents.It was very interesting to watch and was the first open abdominal surgery I have seen. I felt bad for the patient though. In the end, the surgery didn’t reveal anything. She would be in the hospital recovering for the next 6 days and probably off the job for the next 3 weeks. She had no insurance either.


With respect to the open vs. laparoscopic decision made in this case - I think that surgeons may forget the impact that an open procedure may have on the patient. The open surgery seemed so simple and straightforward. It is hard to imagine that recovery could be so different.


After that surgery I went home for the night. I learned a lot from this shadowing experience. First, it seems like residency is a completely different world from med school. I enjoyed talking with all the residents. Although overworked, they were all very upbeat and excited. It was nice to talk with someone that is on the other side of their training. I got to go to the OR again which is always a good time. I like seeing how everything works in the OR, the surgical staff, the instruments, and of course the surgery. The "lap chole" (gallbladder removal) would prove immensely beneficial to the patient. Dr. S mentioned that if we went to his room later that night he would probably be feeling much better already despite the surgery. At the same time it was sad to see patients have to go through so much, knowing that they have a long recovery, possible complications and large expenses ahead of them. The last two procedures I saw didn’t necessarily help the patients either. At best, they ruled out a diagnosis but didn’t find the problem.

Tag!!!

A few days ago I decided to humor Mia, my two year old daughter, with a little game of tag. I always found tag a little boring with just two people but I figured she would enjoy learning a new game and it was a chance to prove to myself that I have enough energy to be the father of three children under three years old.
She caught on pretty quick except I think she liked being "it" more than having to run away. After I tagged her she would run up against the side of the house no more than ten feet away and giggle her head off until I tagged her or convinced her to run a little further.
She is also pretty good at the art of deception. After chasing after me to tag me for a few minutes she would stop and say: "Oh, I was just kidding." Then she would slowly walk closer until she was in striking distance, tag me and laugh her head off.
I tried to teach her the proper lingo of the game: "Tag - you're it." Halfway through the game, she tagged me, but hesitated as she tried to remember what to say. After a second she said, "Tag, its your fault!" I guess it was.

I'm Busy