Friday, March 18, 2011
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.
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.
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.
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.
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.
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.
Sunday, May 3, 2009
Fish!
There is a fine line between "hobby" and "mental illness." -Dave Barry
I thought I would post a few picks of my latest (and only) hobby. It's is a small 28 gallon fish tank with 6 glo-fish, 1 powder blue dwarf gourami, 2 bronze corydoras catfish, 1 Corydoras sterbai catfish, a clown plecostomus (I think he is still in there somewhere) and a small colony of red cherry shrimp (If I can't eat em' anymore, I'll raise them.)
The glofish are green (yellow under normal lights), orange and red. They are actually zebra danios that have bee genetically modified with flourescent proteins isolated from jellyfish. The gene is now a part of their DNA so they can actually pass it on to their offspring. I believe they are the first genetically modified pet.
I built some moon lights for the tank out of some blue LED's. They make the glofish really, well... glow. It makes for a cool camera effect.
The gourami is kind of the bully of the tank. I have to turn out the lights comletely at night so the catfish can eat their sinking wafers without getting harrased by him. And man can this fish can poop!
The bronze catfish are kind of ugly but fun to watch. Along with the Sterba cory they help keep the bottom clean. They actually kind of look like mice.
The spotted one is the Corydoras Sterbai catfish. He swims pretty well with the others but I think I would like to get him/her/it a companion or two. My tank is pretty maxed out and I'll either have to get rid of the plecostomus or build a sump, which expands the water volume of a tank.
I'm not sure how many shrimp I have and I am about to have some more. I have at least seven that I have been able to count at any given time. I noticed one of them was carrying eggs the other day. They are prolific breeders. I am going to put them in a smaller tank and start breeding them. I might be able to make enough money off them to pay for the rest of my hobby. The picture below is a juvenile female. As they mature, the females turn a deep cherry red color. You can see a light colored "saddle" on this one which is actually the developing ovaries.
The clown plecostomus is a recluse. He only comes out at night. But he is pretty cool/ugly looking. He reminds me of the monk fish from Pike's Market in Seattle -the one they use to scare the customers with. I don't have a pic but you can see one here.
I thought I would post a few picks of my latest (and only) hobby. It's is a small 28 gallon fish tank with 6 glo-fish, 1 powder blue dwarf gourami, 2 bronze corydoras catfish, 1 Corydoras sterbai catfish, a clown plecostomus (I think he is still in there somewhere) and a small colony of red cherry shrimp (If I can't eat em' anymore, I'll raise them.)
The glofish are green (yellow under normal lights), orange and red. They are actually zebra danios that have bee genetically modified with flourescent proteins isolated from jellyfish. The gene is now a part of their DNA so they can actually pass it on to their offspring. I believe they are the first genetically modified pet.
I built some moon lights for the tank out of some blue LED's. They make the glofish really, well... glow. It makes for a cool camera effect.
The gourami is kind of the bully of the tank. I have to turn out the lights comletely at night so the catfish can eat their sinking wafers without getting harrased by him. And man can this fish can poop!
The bronze catfish are kind of ugly but fun to watch. Along with the Sterba cory they help keep the bottom clean. They actually kind of look like mice.
The spotted one is the Corydoras Sterbai catfish. He swims pretty well with the others but I think I would like to get him/her/it a companion or two. My tank is pretty maxed out and I'll either have to get rid of the plecostomus or build a sump, which expands the water volume of a tank.
I'm not sure how many shrimp I have and I am about to have some more. I have at least seven that I have been able to count at any given time. I noticed one of them was carrying eggs the other day. They are prolific breeders. I am going to put them in a smaller tank and start breeding them. I might be able to make enough money off them to pay for the rest of my hobby. The picture below is a juvenile female. As they mature, the females turn a deep cherry red color. You can see a light colored "saddle" on this one which is actually the developing ovaries.
The clown plecostomus is a recluse. He only comes out at night. But he is pretty cool/ugly looking. He reminds me of the monk fish from Pike's Market in Seattle -the one they use to scare the customers with. I don't have a pic but you can see one here.
Friday, September 12, 2008
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?
Saturday, September 6, 2008
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
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
Sunday, August 24, 2008
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)
Saturday, August 2, 2008
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.
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.Sunday, July 13, 2008
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.
Saturday, June 21, 2008
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.
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.
Sunday, June 15, 2008
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.
Monday, June 9, 2008
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.
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.
Sunday, May 25, 2008
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.
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.
Sunday, April 20, 2008
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