Saturday, July 30, 2011

Trauma Surgery: Day 17

Was in from 6a-545p. It took us about 7 hours to round with the attending, which is a new record! We started, as we always do, with our sickest patients first. Got through with the SICU patients and moved quickly upstairs to the MICU to work with our motorcycle injured patient. The blood pressure kept dropping despite our best efforts: we gave full doses of 2 vasopressors, increased his blood volume by increasing the saline drip and fluids, and decreased the diuretics. There are 5 main causes of shock: Cardiogenic (associated with heart problems, like an MI, Cardiac Tamponade, Cardiac Contusions); Hypovolemic (associated with low blood volume, like loss of a lot of blood, dehydration); Anaphylactic (associated with response to an allergen); Septic (associated with infections and immune response); Neurogenic (associated with injury to the brain or spinal cord). This patient was clearly in some form of shock, since the blood pressure was low AND his heart rate was low. Normally, when our blood pressure drops, such as when we stand up from laying down & our blood rushes to our legs, our heart rate will increase to compensate. So normally, a low blood pressure and increased heart rate go together, and high blood pressure and low heart rate go together in response to a change in our set values. This patient was experiencing low blood pressure and low heart rate. So the question was: what type of shock is going on, and how can we treat it? We gave vasopressurs (addresses cardiogenic shock: we wanted to increase the blood pressure to counteract the slow heart rate), we increased the volume repletion and gave blood (addresses the hypovolemia), there were no allergic reactions suspected (no need to address anaphylactic); we gave diuretics and watched the sodium and electrolytes carefully (to support the patient's healing process of the brain and spinal cord). In essence, we were doing about everything we can to support the patient. We ended up giving some more blood, as there was a lot of blood loss previously, in an attempt to address hypovolemia. The patient's stats improved. We are hoping for enough improvement to be able to be stable enough to get a CT scan, so we can see what's going on in the brain. The patient is heavily sedated to keep his intracranial pressure down (which helps to support the patient's ability to heal the brain), so we can't do very accurate neurological exams. A CT would help us to better see what is going on. The overall prognosis can't be determined at this point, we need a CT scan to be able to better assess the long-term outcomes.

After work, Mike & I (and Marley) went straight to a soccer game...I kind of watched him play, but I also read/studied for about an hour. I have got a whole lot to learn before my shelf exam on September 9th. It seems like a long time from now, but I know it will sneak up on me and before I know it, I won't have enough time to cram in all of the information I'll need for my exam. This stuff sure is a lot of work!!! but TOTALLY worth it! :) :) :)

Thursday, July 28, 2011

Trauma Surgery: Day 16

6a-5p today. Another busy day in the trauma life! The head of surgery was our attending for today, so we got another good lecture from his after our rounds. He is a definite asset to the medical school; he values education and medical students very much, and always makes me feel like I am really a part of the physician-team. We talked about Acute Pancreatitis, which is the condition that one of our patient's is suffering from. He is doing better, remarkably. Hopefully his labs continue to improve and he will come out on top of this. When he came into the SICU yesterday, the mortality was something like I calculated it to be around 5%. As long as his condition continues to improve, he will be able to go home. The pancreas is probably non-functional, though, so he will be on strict insulin and pancreatic enzyme replacement therapy for the rest of his life. Many other complications can occur, such as malnutrition, GI obstruction, and transverse colon ischemia. It is a really serious illness.

The motorcycle trauma I spoke of yesterday is being excessively monitored for any changes in the condition. I am becoming more competent in reading radiologic studies, but there is a long way for me to go before I feel comfortable. I'm getting the hang of reading chest x-rays. The CT of this patient's head and neck is truly impressive. With the technological advances in imaging, we are now able to take the 2-D images from the CT scan and, using a clever software program, we can obtain a 3-D image that we can manipulate in many ways, like moving it in any direction, visualizing blood vessels, bones, tissue, skin, air, blood, and many others. It is really cool to be able to see things from so many different perspectives, it makes it easier to catch all of the little problems going on in a really injured patient.

Here are the CT images of the head from this frontal bone fracture. The brain was actually visualized through the bi-frontal bone fracture upon physical examination...

If there is any lesson to be learned here, please! please! if you're going to ride a motorcycle or dirtbike or four-wheeler or ATV, please! please! wear a helmet!!!!

Wednesday, July 27, 2011

Trauma Surgery: Day 15

woah, day 15 already?! Time is just flying by! Was in today from 6a-7p. Did a bit of pre-rounding paperwork before our M&M (Morbidity and Mortality) and Grand Rounds conference, which was from 7-9:30. It is sooooo hard to stay awake in a dark room with soft-speaking lecturers talking about the details of a particular case. The lecture was on Deep Brain Stimulation, a topic which I love. It is used most notably for Parkinson's patients that no longer react to medications or suffer moderately to severely from the side effects of the medications. We were taught in med school that you place the electrode into the Globus Pallidus Interna, but you can actually place it into the substantia nigra as well...If you understand the pathways, this therapy is intuitive. I won't bore you with those silly neurology pathways! ;) They are actually making progress in the utilization of Deep Brain Stimulation to treat refractory depression, Obsessive Compulsive Disorder, Obesity, and Addiction. You just place the electrode into different specific locations within the brain, make it stimulatory via electrical currents, and watch the patient improve. It is truly one of the most impressive treatments in medicine. A man that shakes and shakes is in the operating room while an electrode is placed into the proper location, at which time he stops shaking and regains fine and gross motor control. It brings tears to my eyes every time I see a video of it happening, it is really amazing what we can do to improve a person's quality (and quantity) of life. On an important side note, DBS actually is more cost-effective long-term in comparison to the long list of medications that a patient must take in order to achieve similar effect (plus drugs inherently have adverse effects!).

This man has Essential Tremor (but the effects are similar to Parkinson's):

2 Traumas today, but motorcycle accidents. The first one had a horrible head fracture. I actually saw the brain through the facial was a very impressive site. The patient will be in the OR and then we will follow on our service. With brain injuries, all we can do is support the patient (keep the intracranial pressure low, the cerebral perfusion adequate, the blood pressure optimal, etc), but we can't fix what's broken, so to speak. The brain is too complex to just stitch back together again, like a bone or skin...we do everything we can to give the patient the best chance of making a full recovery, but the end results are, ultimately, out of our control. The patient has to do the rest. It's a slow and difficult process, but it feels so good when they pull through better than you could expect.  I know this is not always the case...    The other MCA was relatively minor, as far as we could tell by the preliminary reading of the X-Ray and CT scans.

A man came in with acute pancreatitis. He has familial hyperlipidemia, which predisposed him to acute pancreatitis (lipase, an enzyme secreted by the pancreas, helps to breakdown fats... and a person with hyperlipidemia has a lot of fat, stored as triglycerides, in the arteries). His prognosis is poor, and we can only support the patient until his eventual and inevitable decline, during which time we will actively resuscitate him with fluids and replacements, and possibly go in to the OR to repair the peritonitis and clean up the pancreatic enzymes as best we can. I need to read up on this...the presentation was a lot like we learned it to be in medical school (excrutiating pain that radiates from the epigastrium to the back; grey-turner's sign; acute onset). So I will end the day with a few loose ends about this particular patient, but I will be sure to fill you in on all of the exciting details tomorrow!

Tuesday, July 26, 2011

Trauma Surgery: Day 13 & 14

whoops, no time to blog yesterday! was in 6a-7p, got home, had dinner, and fell asleep while Mike was showing me the photobook of us that he's been working on at about 8:30!

Today was a better day, a well rested mind makes the morning a lot easier to get through! Was in from 6a-6p. 12 hours, holy cow, only 12 hours today! Saw two interesting cases:

A man came in with a femur fracture and nasal fracture from a fall out of bed...he has Osteogenesis Imperfecta. This is a relatively rare disease, so I was more than excited to meet him! Osteogenesis Imperfecta (OI) is also commonly known as "Brittle Bone Disease". The cause is a genetic defect in the Type 1 Collagen fibers that make up parts of our body that include most notably bones, but also sclera, skin, and endothelial tissue. The partnership with OI is Blue Sclera; That is to say, often a patient with OI has a bluish tint to the "whites" of his/her eye. Due to the collagen defect, patients suffer from repeated fractures throughout their life. This patient said he has had over 150 fractures so far. He is a lucky one, though; many OI patients die in childhood. That of course depends on the specific genetic cause of the disease, and there are 4 differing types of OI, with different prognoses and disease progressions (In case you want to learn more, this man probably had Type 3). He also happens to have a very impressive goiter. He was definitely the patient of the day for me! :)

A woman came into the ER as a Level I Trauma, found in cardiac arrest at the scene and was undergoing CPR by the paramedics at arrival. We continued CPR (it's more of a workout than you might imagine!), adjudicated her therapy with medications (Epinephrine, Bicarbonate, ), and attempted cardioversion, but after about an hour of our best efforts, it proved to be unsuccessful. That was hard to see...I have seen so many patients pull through traumatic injuries and poor health in the SICU/MICU, this was the first time I saw our efforts to be completely ineffective.

Tomorrow is another day...I am nearing the end of my trauma service on surgery, but I have had a really great time in this rotation. I would definitely recommend it, good exposure to patient care and management, as well as difficult management of very sick patients, with minimal time spent in the operating room - my ideal surgical service!haha

Quote of the day: The head of our Surgery Department rounded with us today. We have spent some time with him in the last two weeks, and he is a really great teacher and a great role model physician. Today, he said to my trauma service partner and me: "I have been in this business a very long time, and I know when I see students who will make excellent physicians, and you are very bright students. You are well on your way to becoming very successful physicians, keep doing what you're doing, keep working hard, and I promise you that it will pay off."

Sunday, July 24, 2011

A Weekend Off!

I have had such a great weekend away from the hospital! Mike & I started planning our wedding, just working on some of the big picture things like a venue and what we both want from the wedding, and our expectations. It's crazy how different we are in how we envision a wedding...Being from 2 very different cultures has never been an issue before, but we are definitely on different standpoints on what we expect from a wedding. We both know that, since we are such a unique couple, we will not have everything match up to what we have imagined our whole lives, and there will obviously by some compromise. But the most important part of the wedding is committing every bit of our lives to each other forever, and we are definitely ready to make that happen! So the rest is really just details, right?? ;)

We went on a night out with Gina and Ben last night, and had such a good time. I'm so thankful to have such thoughtful, giving, and encouraging friends that I can just sit back and have a good time with. It's nice to leave the medicine behind and talk about other things all night long!!!

Yesterday, Mike reminded me that I haven't actually celebrated passing my Step 1 yet...and he took some time to help me feel grateful for passing ("Imagine if you had to take it all over again AND work these hours?!"..."How would we ever finish with your MD in the next two years if you hadn't passed?"..."You worked hard and you got what you deserved, there's nothing you can't do with a little effort!"). It forced me to think about just how lucky I really am. Every day I thank God for blessing me with a life better than I ever could have imagined, for meeting the man of my dreams, for allowing me to reach my full potential and make a difference in the world as a physician...but I've been even more mindful of it this weekend. I have such a great family, such an absolutely perfect soulmate, great friends, a career most people only dream of, and good health and good fortune in so many aspects of my life...I am so lucky. I am so thankful. I am so thrilled to be given the life I have worked so hard for... "To whom much is given, much is expected." Let's hope I can live up to all of the talents and blessings that I have been given.

In short, I am one extremely happy girl. Things just keep getting better all the time!!! :)

Friday, July 22, 2011

Trauma Surgery: Day 12

Was in today 6a-6:45p. Not much new happened...still rounding on patients and learning more about drugs and pathophysiologies and treatments. I helped remove 2 central lines (a femoral line and a subclavian line). My very first trauma patient (with the epidural hematoma due to a motorcycle accident) was moved to the Physical Medicine and Rehab unit. He is nearly back to his baseline status; I am so happy to see him doing so well. Since he was extremely sick and heavily sedated during the time which I helped care for him the most, he doesn't know that I have been following his status and improvement day-by-day since his first moments in the ER and then the hospital. It will be a happy day when he goes home. Success #1! :)

In the Surgical Intensive Care Unit, we have "Computers-On-Wheels", which help us during rounding when we are presenting new information to the attending, including labs and imaging...We call them "COWS"...and my family never thought they'd see the day when I would be working with COWS!!! ;)

A Cow ("Computer-On-Wheels"), next to the red crash-cart:

Mike & I were going to begin our wedding planning tonight by deciding on a few venues to check out this weekend and next...but I realized that our tentative wedding date is exactly 666 days from today, and decided not to chance it and so we're going to push off any planning until tomorrow. That's just a bad omen to start planning on such a devilish number!! It's best to be safe and hold off for another day!haha

I have the weekend off to spend with my love and my pup. I am so excited to sleep in tomorrow!! I'm sure I'll be up before 8, but that is a big improvement from what time I normally get up!

1 week left of trauma surgery!

Thursday, July 21, 2011

Trauma Surgery: Day 11

Today was my shortest day yet! 6a-5:15p, doing the usual pre-round paperwork and interviews, followed by a few hours of rounding with the attending. Today we had a few lectures as well: one was on ARDS and the use of a smaller Tidal Volume respiration for treatment, one was on Hepatocellular Carcinoma (HCC) classification and surgical criteria. The last lecture was on DVTs (Deep Vein Thrombosis) and PEs (Pulmonary Embolism). I feel like my knowledge and capabilities are starting to shine through; Even though I spend a lot of time on paperwork, I am still learning so much every single day...from interpreting labs and CTs, to understanding mechanisms of pharmacology, to applying physiologic principles to solve a pathologic problem. I am so definitely NOT a surgeon; my personality is so far removed from a surgeon's that I find it hard to imagine that we could ever really get along. Many of the surgeons are very overly confident, self-reliant, and presume themselves to be god-like. That is so not me. Give me a complex case, I'll sift through the details and come up with a sound diagnosis, assessment, and plan...don't give me a facial fracture that needs to be fixed. I want a difficult diagnosis. So at least I'm learning a little bit about myself along the way as well!

Yesterday, we had a lecture on how to teach others, and how to learn from each other. It was said that, in order to be considered an "expert" in any field, it takes at least 10 years of experience and 10,000 hours of purposeful and supervised practice. Since I only started to see patients last week, I have a really long way to go! But I'm looking forward to the challenge...

Since I got out of work by 5:15 today, I had time to sit out on the patio and bask in the glorious heat and sun - and read one of my wedding magazines!

 I am trying to find some time to begin the organizational portion of wedding planning. The first thing I want to do is find a venue that suits our style and taste, and matches our vision of our wedding perfectly. Not sure where to even look in Toledo for what we would want, but we're going to start on it properly soon. We feel like we've had our time to sit back and enjoy being engaged, and we're ready to move on to enjoying the exciting time of planning for our wedding, and it would be nice to have a date officially set! :)

Wednesday, July 20, 2011

Trauma Surgery: Day 10

6a-7p today. I saw 2 different Level 2 traumas today. In between them, I did paperwork, attended a 2 hour meeting, made rounds with the attending for over 4 hours, and helped discharge patients.

My first-ever surgery patient is doing really well. He's on the "step-down from surgery" unit, up and walking down the hallways. He is doing really well, it just makes me smile.

Yesterday's ethical situation which I eluded to was brought to a peaceful and dignified closure today. Aggressive therapy was discontinued and comfort care was initiated. The patient was at peace with the world, leaving on her own terms and without pain or discomfort. This is my first experience of death as a student-doctor. I have had a patient die literally in my arms when I was a nurse's aide, so, although no death is easy to accept, I feel that witnessing a patient die peacefully and dignified and in the company of family and friends is much preferred to a sudden and unexpected end of life.

On a much happier note, I put in my first suture today!!! It was a single, interrupted suture of a foot laceration. I even was the one to inject lidocaine into the area surrounding the injury prior to the suture. It was a really great way to end the day! And the suture looked really great, symmetrical and provided good closure. Not bad for my first go!!! :)

Trauma Surg is officially halfway over! I signed up for my next clerkship, which begins on September 10th. I will be doing Pediatrics for 5 weeks followed by OB-GYN for 5 additional weeks. It will be a nice change of pace to the whole surgery lifestyle! I'm looking forward to it already!!! :)

Tuesday, July 19, 2011

Trauma Surgery: Day 9

I was in today from 6a-7p...short day! ;) I did some paperwork, interviewed and examined patients, and then rounded with the attending. There was another Level 1 Trauma today, who was life-flighted in with an open, compound humerus fracture, pelvic fracture, femur fracture, tibia-fibula fracture, and a frontal bone fracture with a pneumocephalus. It was really impressive, the fractures were just so obvious. I'm still finding it hard to see someone in such a traumatic state, but I am beginning to be a little less emotional and a little more calm-minded about such notable traumas.

The motorcycle patients continue to recover. If you must insist on riding a motorcycle, at least please wear a helmet. If you ride often enough, a crash will occur and it is life-saving to have a helmet on. I hate motorcycles now. They are so dangerous, I can't even see the point in having one. If everyone had to see a patient come in and slowly recover (if he's lucky!), motorcycles would be a thing of the past...but regardless, you can at least wear a helmet!

The thing that has been bothering me the most is caring for a terminally ill patient. For instance, a scenario in which a patient who has stage 4, terminal cancer will succumb to their illness; when do we cease our efforts while maintaining optimum patient care congruent with the patient's wishes of dying a dignified and humane death? It breaks my heart to see a patient struggling on a ventilator, sedated out of any form of consciousness, and dying of a terminal illness. Where is the line drawn between doing what the family wants vs. treating the patient with dignity, compassion, and respect during the final days of life? Where is that distinction made?...this is definitely something I'll be dealing with and thinking about a lot for the next 8 weeks (and inevitably for the rest of my life). Not a pleasant thing to think about, but it is very important to develop an opinion on what I believe to be optimal care for the patient's end of life care.

Monday, July 18, 2011

Trauma Surgery: Day 6, 7, & 8

What a weekend! Phew! I clocked in over 36 hours this weekend: Saturday 6-2, Sunday 6a-Monday 10a... and it was busy. Summer time brings out all the trauma: motorcycle accidents (there have been far too many epidural, subdural, and intraparenchymal hemorrhages!), softballs/baseballs to the face, outdoor falls, and MVAs.

The first patient that I have seen through admission until post-op is doing really well. He had a huge epidural hematoma; I was with the team when he came into the trauma bay, through the CT scans, and watched his epidural evacuation operation. After we extabated him and he came to a few days after his accident, one of the first words he said was a raspy and sincerely heartfelt "thank you". I can't tell you how good that makes me feel; medicine is unbelievable. He is now alert and responsive, and will be discharged soon (provided things continue to do well, which we expect to be the case). I'm so happy to see him doing well.

This weekend involved a few Level 1 Traumas, so I have been a busy girl. I am learning so much so fast; this is definitely the way to learn medicine, not by the books. I absolutely love seeing patients, managing their ailments, and serving their needs. Even if I have put in nearly 100 hours in the past 7 days, I am still loving it. I miss having a life, but I am coping. I miss Mike a whole lot, but I don't think things will get much better for a long time!

This weekend, Mike & I saw Harry Potter, which was great. Then we went to a friend's house on Saturday for dinner and drinks (I of course was in work at 6a the next day - welcome to the glamorous life of a physician!). Today I totally got my long list of chores done - 6 loads of laundry, grocery shopping, bills paid, research completed, everything! I haven't slept yet, but I am so glad to have had some time to get my everyday needs completed at least once this week!haha

woooooooo fingers crossed, I will have this coming weekend off so I can actually spend some time with Mike and Marley!!! :) :) :) :)

Friday, July 15, 2011

Trauma Surgery: Day 5

Phew. I'm up to 65 hours of work this week and I'm in tomorrow and Sunday so this will be short. I'll fill u in tomorrow about today...was really good tho. Happy to see my patients recovering so well!

Went to see Harry potter with mike, Gina, Ben, John, and Abbie tonight. So sad to see the end of Harry!!! Was a really good film great way to end the long story.

Thursday, July 14, 2011

Trauma Surgery: Day 4

ahhhhhhhhh I scrubbed in to my first operation today!!!!!!!  It was a life-flighted Epidural Hematoma. It was amazing. Seriously, what a rush! I saw him come in, and I stayed with him until he was stable in the medical ICU room...which was about 7 hours. How cool. I wanna tell you all about him, but here's a quick rundown: a man hit his head, walked home thinking he was ok, then fell asleep on the floor where he was found. Typical Epidural Hematoma scenario: A head trauma, a lucid interval where things seem ok, then a medical emergency. This is what Liam Neeson's wife died from. Luckily, he came into our department in time to be resuscitated. He was alert and oriented before surgery. The CT scan looked just like what you read in textbooks; I know I said it yesterday, but it is SO COOL to see real people with these problems rather than just cases in a book! Anyway, I scrubbed in and stayed for the entire surgery. It was sooooo cool. Seriously. And I'm not even into surgery, I have no real interest in it. But it was really amazing; He would have died without intervention; the doctors today saved this man's life. This is why I love medicine. Just amazing.

I was in from 6a-8p. Phew. I'm whipped.

Oh yea, the patient from yesterday, with the CNIII palsy, is recovering. We found the lesion on the MRI, and this patient is actually getting better, albeit slowly. That's really reassuring. Such amazing things happen every day in medicine!!!!

Wednesday, July 13, 2011

Trauma Surgery: Day 3

Let me start today by saying... I passed my step 1!!! I did score a bit below my goal, but I am really happy with my result! I worked hard for this... 12-14 hours a day, every day, for 6 weeks and 2 full years of solid education and revision all led up to a good score. I'm thrilled!!! This was the last real obstacle to get through on my way to becoming an MD. Graduating top of the class in high school and college, getting in to an above average medical school, passing my first two years and my step 1... the rest should be easy in comparison!! Well, we're still talking long days and no free time, but I will get thru the rest and come out with the life I've always dreamed of!!

Today was a good day, I found out my score on the boards around noon, during our SICU rounds actually!! Followed some patients, read some of my surgery text, then followed up in patients. We had a lecture on physician suicide, and I hope to enlighten you with some astounding facts and stats about physician mental health and lifestyle in tomorrow's post!

I have already worked more than 40 hours this week. No complaints, though; I love to be busy, I couldn't imagine a life without school and/or must be so unfullfilling especially since I am now able to do exactly what I've always dreamed of doing!!

Oh yesterday's 3rd cranial nerve palsy patient had a lesion at it's exit from the pons...this person will likely never recover from this injury...

Tuesday, July 12, 2011

Trauma Surgery: Day 2

I was only in from 6a-6p today, so I actually have some time to spend with Mike!!! :) We started the day with 6 patients, then discharged 3 and sent 1 in for surgery and had no new admits, so you can imagine today went pretty smoothly as compared to yesterday!

An interesting case of the day: A patient presented to the trauma service, and s/he has a textbook-variety Cranial Nerve III Palsy: This nerve supplies innervation to most of the eye muscles, the upper eyelid muscles, and parasympathetics that cause pupillary constriction. So, with a CNIII Palsy, the eye is forced in a "down and out" position, the eyelid is unable to open , and the pupil is dilated and unresponsive. I can't even tell you how much more educational a real patient is over a textbook or lecture! It was really interesting to see. CNIII palsy results from damage to the oculomotor nerve anywhere along its course, from the nucleus in the dorsal mesencephalon, through its fascicles in the brainstem parenchyma, to the nerve root in subarachnoid space, or in the cavernous sinus or posterior orbit.  A common causes of CNIII Palsy include Increased Intracranial Pressure; an uncommon cause is an expanding aneurysm in the Posterior Communicating Artery (PCA) in the brain. This patient was particularly interesting because we could not determine the cause of the palsy. After many scans and consults, we can't say why it occurred...which is a rare phenomenon. This so-called "isolated CNIII Palsy" often resolves spontaneously within 3-6 months.

I may be the first person in the history of Danskos to actually NOT love legs have never felt so horrible and swollen in all of my life as they were last night after 14 hours of wearing them. I'm going to try them again sometime this week, but ouuuuuuuch I am waiting until my pain subsides a bit. I spent half of my day studying (since it was a slow day, we were told we could study and wait for a trauma page if a trauma case was to come), so my legs got a nice half-day off! Listen to me, its only been 2 days and already I'm complaining! ;)

Monday, July 11, 2011

Trauma Surgery: Day 1

Woooooooah...what a day! I was in scrubs and waiting for my resident by 5:30a. I was so nervous that I would get one of those stereotypical surgery residents, that are manly men and are domineering...but I was pleased to find that my residents are the exact opposite! They have been so helpful in teaching me already, and they understand that it was my very first day ever on the wards, so they didn't push too far.

We checked on all of the Trauma Surgery patients from 6-10, then rounded on the SICU (Surgical Intensive Care Unit) with the attending from 10-12. I took a quick surgical assessment risk survey for one of my patients, then ate a quick lunch before working in the clinic from 1-6. From 6 to 7 we rounded on our Trauma Surgery patients with the attending, and finished the night checking over tonight's to-do patient lists and taking one last look at our SICU patients. I finished my first day at 8p. Nothing like jumping straight in to 14+hour work days!

Saw many interesting patients...I have so much to learn & the opportunities that the patients present to me are endless.I won't have to do many surgeries in the next 3 weeks either, which is good so I can focus on patient management rather than surgical procedures!

My first patient was...believe it or not...a colon cancer survivor! It was a post-surg follow up appointment... I don't know of many people that would be excited to have a colon patient as their very first patient, but I was thrilled!

Now I need to do a bit of research and prepare a presentation for tomorrow before I can finally kick back and relax (and of course SLEEEEEP!) Tomorrow starts by 6am. oh boy! ;)

Tired Feet!

Sunday, July 10, 2011

This weekend has been so much fun! On Friday, Mike & I invited Gina & Ben around and had dinner and sangria, watched a film, and caught up on each other's lives...On Saturday, the four of us went to the Toledo Lighthouse Festival, which was a little quieter than we expected it to be, so we decided to go to Ben's Dad's house and take a ride down the river with his boat. We went all over, up to the Lighthouse and up and down the river, inlets, and bays before having a seafood dinner at a little restaurant on the water. It was such a good time, I love being on the water on a scorching hot day! Ben's Dad & his wife are legends, they are so laid back and welcoming, two really great people.
Mike and Me on Saturday Afternoon:

Today, Mike & I went shopping...oh how I miss Liverpool One! I think we're going to stick to only shopping while in England...but it was fun to see some of the sights out and about in the mall on a Sunday afternoon. Yikes. We even went to get my ring cleaned and look at wedding bands; the jeweler we bought the ring from left the mall, but there's one near my mom and dad's house so at least we don't have to travel far for inspections/tightenings/cleanings for the engagement ring. I have my eye on a few different wedding bands...but we do have 2 years to commit, so we have plenty of time to find the perfect ones!

Marley kisses!

Today, I spent the most amount of money I've ever spent on a pair of shoes on the ugliest pair of shoes I have ever laid my eyes on...
...welcome to the world of medicine, where 16 hour work days make comfort trump style! Nurses & Doctors swear by Danskos...fingers crossed I fall in love with them, too. I'm a bit skeptical at the moment, I just can't get over how disgusting they are! But as long as my feet aren't killing, I'll be one happy MS3!

I paged my residents a few times Friday, Saturday, and today...never got a call back. I have no idea when I need to show up, where I need to show up, and in what attire I need to be, but I suppose I will find out tomorrow when I show up for surgery at 5:30am! Let's hope they don't expect me sooner...fingers crossed for a good day tomorrow, I am a bit nervous, but I'm also really excited to finally put some of my hard work to good use!! :)

Check back tomorrow to see how my first day goes!! :) :) :)

Saturday, July 9, 2011

Surgery: Day 4

Orientation week is finished! I start on the Trauma Service early Monday morning...! I'm REALLY excited to see my first patient!!! I still need to buy some books, find a decent pair of shoes, talk to my resident to see when and where I need to meet him on Monday, and learn everything I can about documentation/SOAP notes/taking a good H&P before Monday morning...!

Lectures ran from 8:30a-6p (I got to sleep in until 7 so that's a good start to a Friday!). I had a suture lab this morning; we learned how to do vertical and horizontal "mattress sutures" and how to tie surgeon's knots. Last week, I was taught how to do "Simple Interrupted Sutures". This technique is basically putting the needle in the far side of the wound, passing it through to the near side, and then tying a surgeon's knot to hold the suture in place. These sutures take a lot of time to place, but they allow for greater tension and, if followed-up properly, can reduce the risk of scarring.
Illustration of a Simple Interrupted Suture 

Today, we practiced the "Vertical Mattress Suture". This is useful for really deep lacerations, as it allows the subcutaneous tissue to be brought together separately from the dermis, but that also means that there is room for placement error by the physician's suturing. It also has a fairly high risk of producing a "railroad-track scar". The technique is "far-far, near-near", which is labeled below as needle strikes "1, 2, 3, 4".
Illustration for the Vertical Mattress Suture:

Here's a picture of how I sutured my pig foot's laceration:

...I have some work to go before I will feel absolutely comfortable with suturing, but I'll get the time to perfect my skills when I am closing up skin after surgeries! :) :) :)

A few good quotes from today:
"Being a physician is the noblest profession; To me, teaching is the second noblest, and we, as physicians, have the opportunity to be a part of both. Share your knowledge, it will be your legacy." - Dr. G
"The safest place in the hospital is the Operating Room." - Dr. O


Thursday, July 7, 2011

Surgery: Day 3

In lecture today from 7:30a-6:30p, but it wasn't so bad as the lectures were interesting and kept my attention well.

A few quotes from today:
"There are 2 instances where it is not indicated to give a rectal exam: If you don't have a finger, and if the patient doesn't have a rectum. Either put your finger up there, or you'll put your foot in there!"
"Calcitonin is like a white basketball player; it looks good, but it doesn't do a damn thing."
"You will have plenty of time to discover new things, but not in the breast, son!" (in reference to determining the type of nipple discharge)

Today's Clinical Pearl: 10% of people travelling from the US to the UK (or from the UK to the US) will get a DVT (Deep Vein Thrombosis). That's 1 in 10 people. Next time you take a trip across the sea, remember to get up and exercise a few times during the flight to keep the blood from pooling in your legs and possible clotting. For many people, the DVT will be cleared by their own t-PA and fibrinogen, but for a few unlucky ones, the DVT is not cleared, and a Pulmonary Embolism can prove to be deadly. So, if you are going to be crammed in a seat for 8 hours (long flights, long drives, long lectures), be sure to move those legs several times to keep your blood flowing properly and to decrease your chance of forming a clot!

Since it's that time of the year when we all love to be a gorgeous sun-kissed tan color, I thought it might be helpful to explain a few things about the sun and our skin! As a historical background, up until the 1920s, it was considered taboo and quite "working-class" to have any color on one's skin. This all changed when Coco Chanel  accidentally got sun-burned while visiting the French Riveria, and the fashion-forward Parisians fell in love with the look and haven't looked back since. Since this revolution in culturally-defined "beauty", the incidence of skin cancer has been consistently rising.

You might be aware of the different types of ultraviolet radiation - UVA, UVB, and UVC. UVA comes from the sun and it is the main form of UV light in tanning beds. UVA causes permanent damage to the elastic tissue in our skin.UVB is moderately carcinogenic, and comes from the sun and is found in tanning beds. UVC is highly carcinogenic, but thankfully the ozone layer filters this out. UVA and UVB differ in the way they tan our skin as well. UVA provides nearly immediate tanning, but the pigment in our skin is short-lived. This is what tanning beds primarily use. UVB takes 48 hours for tanning to occur, but the pigmentation lasts longer.So you know how you can always tell when someone has been to the tanning beds versus a nice beach vacation by the orange-tint? Well that's the UVA doing its job. And the late effect? Permanent damage to the elastic tissue in our skin, something we can't get back, causing that "leather skin" effect that old ladies sometimes have. So...true or false? Getting a "base tan" from a tanning bed prior to going on a beach holiday will protect your skin from burning while on the beach...True or False? Well, its False. Since a tanning salon provides a tan via UVA radiation, it does not provide protection against the sun's tanning UVB rays.

Most of the moles and freckles that we have as adults came as a result of sun exposure as a child. It is so important to apply sunscreen to children, it is something they will appreciate and thank you for later in life.

So, here are a few healthy tips for keeping a gorgeous complexion: don't go to a tanning salon unless you want to have your face match your leather handbag when you are 40 years old, avoid sunburns especially prior to the age of 21, and wear that sunscreen every day. Get a broad-spectrum sunblock (UVA and UVB protection), put it on 20-30 minutes prior to sun exposure, and reapply every time you dry off. Check your moles for any changes often (it is suggested to have a look at your moles while you do your monthly breast exam). I have my doctor look at my larger moles yearly, just to keep on the safe side of things.

If you have any questions or concerns about skin cancer or a suspicious mole (remember the ABCDE's: Asymmetry, irregular Borders, multi-Colored, large Diameter (larger than a pencil's eraser), and Elevation), please speak with your family physician or GP. It is always best to err on the side of caution!!

Wednesday, July 6, 2011

Surgery: Day 2

10 hours of lectures today; so much for believing that part of my life was over (or at the very least, diminished!). We ended today with a lecture on colorectal cancer. We even learned, in a small amount of detail, HNPCC. We were even told that it can predispose you to cancers other than GI! With my experience, it seemed like physicians were not given so much as a mention of HNPCC, much less understand that it can affect organs outside of the GI system. So I'm happy to know that my classmates will know a little bit about what my family and I have.

"HNPCC has a poor prognosis, but thankfully it is relatively rare." uhm, not too reassuring for me, but I guess the truth must be told. I now realize that if I get cancer, even if it is contained in the wall, it will be a lifelong struggle. It's almost funny how surgeons suggest to handle HNPCC patients. Simply stated, in bold, black print, "a colectomy should be strongly considered", as if it wasn't a big deal to cut out someone's colon, put in a colostomy bag for a while, then eventually attach the small intestine to the rectum. Also suggested: "pan hysterectomy in women not wishing to pursue reproduction". Why don't we just take off the breasts, gut the entire GI system, and remove the GU system and go on lifelong dialysis while we're at it...! *ugh* Its discouraging. Something so near and dear to my heart put in to simple and straight-forward treatment options is quite hard to swallow (pardon the pun!) But enough about me!

Enjoyed a nice walk around the estate with Mike, Marley, and Andrea, and we had sonic for dinner. Yum! I just LOVE this hot, sunny, summer weather!!! :)

Tuesday, July 5, 2011

Surgery: Day 1

Today was the first day of my surgical clerkship! We went over the biliary system, x-ray interpretation, scrubbing in and gowning in a sterile environment, placing a foley catheter, placing an nasogastric tube, and how to place IVs. I didn't have a single story that stuck out to be used as today's "Clinical Pearl", but I did see a pretty graphic x-ray of a flashlight stuck in some man's rectum. I also saw an x-ray of the world's most botched NG-tube insertion - the tube went from the nose up into the brain via a fracture in the frontal skull. How can someone make such an obvious mistake?! "hm...I don't see the N-G tube in the pharynx, I'll just push in another foot and see if that helps..." At least I am confident that my inexperience-induced mistakes won't be as horrible as that!

"Am I safe to assume that you all are the type of people that tear off the top of the cupcake and eat that first? Because you chose to do the best clerkship first!" ( - Clerkship Director)

I love seeing all of my classmates dressed up in their professional attire, complete with our short white coats and stethoscopes. As I was walking with a group of us, I had an unexpected, immediate, and almost surreal sense of fulfillment; I feel like I really am now part of the doctor-team. It's unreal. All of those endless hours learning every little detail of every medical subject is finally being used in a meaningful way. I am beyond excited to finally see patients. I know I keep saying it, but I have worked for the last 20 years of my life to get to where I am today, and I think I am expected to be over-the-moon about this. I'm scared to make mistakes, but I am gaining confidence in myself each day, so I feel that the transition from student to doctor will certainly happen with time. I am so indescribably happy to be starting with my clinical experience; I truly feel that I am exactly where I am meant to be.

Just as a side note, many of my peers who are beginning their clinical life in different clerkships had the afternoon off. I was in from 7a-6p. Not a complaint, just an observation...Welcome to the surgical life! ;)

OH! And I came home to a spotless apartment and tea made - bangers and mash (which totally hit the spot!). Mike said that since he knew how hard I was working and how busy I am, he thought he could handle the apartment chores. I am a lucky girl!

Monday, July 4, 2011

Happy Fourth of July!

What a beautiful day today turned out to be! I forgot how much I love 3-day weekends, skipping a Monday of work is bound to make the week a good one! I begin my 10 week surgery clerkship tomorrow; We spend the first week in general surgical orientation. Yup, another week of orientation...can't wait. ;)

3 years ago last night, I met the man of my dreams. Reminiscing about those first few days of our relationship is like reliving it all over again. I just love how much better Mike has made my whole life, I am such a lucky girl!

Our friend, Tanja, took photos of Mike and me while we were in Liverpool, and they're up on her blog! If you're interested in checking them out (she did a really great job, so I'd suggest to) click here.

We enjoyed a nice afternoon soaking up the sun on our balcony, enjoying our new patio furniture we got each other for our anniversary. Mike did the BBQ, and we of course had our Corona's open! What a great Fourth of July! 

Hope you all enjoyed the holiday!!

Sunday, July 3, 2011

What a beautiful weekend it has been!!! On Friday afternoon, Mike & I went home to spend the weekend visiting my family. We had a campfire, ate s'mores, drank beer, went fishing, and star-gazed the night away. It was a really great night. Alex is such a talker - he has better communication skills than many people I know. He is so articulate and he always makes me laugh at the things he says. Alex had to correct Mike, letting him know that "it's MARley, not MAHley!!" and "it's HERbie, not HAHRbie!" It's funny that he caught on to Mike's accent and could imitate it so well, we all had a good laugh.

On Saturday, Mike and I played the music for a wedding. This is the first time Mike has played for a wedding, and he did really great. I suggested that he play "In My Life" (Beatles), as he has a really gorgeous finger-pick version that he plays. Since the bride liked it, Mike had a chance to finally show off his arrangement, and it was so beautiful I couldn't help but get a little teary-eyed. The whole wedding mass went so well, and it was really nice to be able to play with my fiance and share in someone else's love story.

We also got to watch our nephew, Luke, for the night. He is full of smiles, and is seriously the easiest baby to take care of. I just love him to pieces, his big brown eyes and big gummy-smile just melts my heart.
Luke & Mike:

Mike also got to meet a few more future-family members, my aunt & uncle that live in Michigan stopped by the homeplace and visited with the family. Nothing makes me happier than to see Mike genuinely happy around my family and home. Even though he is Liverpool through-and-through, he has a deep appreciation for the farming lifestyle, and he has even begun to embrace the culture. This weekend he spent hours fishing, changing oil, starting fires, shooting birds...if only we could get him interested in stacking & unloading bales and milking cows, then he would fit right in perfectly with the family! :)

Since Mike & I met 3 years ago tonight, we're heading out to watch the fireworks display that people across the US put on for us - how nice that they celebrate our love in such an overt way...! Tomorrow, the celebration is for our nation's independence from Great Britain, but tonight it must be for Mike & me. ;)

MSIII: Day 5

Our last day of General Orientation for MS3! We were given lots of advice from residents and from current MS4s. Overall rules for Surgery Clerkship (which is where I begin my year) are:
1.) Work hard. All day. Every day.
2.) Sleep when you can.
3.) Eat when you must.
4.) Don't fart when you're in the OR for a bowel surgery.

Another little pearl of advice: "When you feel like you don't want to bother someone with a question or ask for help, remember: There are only 2 people that pay a whole lot of money to be in the hospital - patients, and you."

Upon concluding the Orientation, we were given our pagers. 
"Welcome to the Team"

...and my first night on call will be in less than 2 weeks!