Tuesday, August 30, 2011

Surgical AHEC: Day 6

Was in on Monday from 7a-1:15p. We did 3 laparoscopic cholecystectomies and a sigmoidectomy (removed the sigmoid colon and reattached the loose ends after taking it out). I'm getting more comfortable with throwing stitches, and I am really enjoying being able to participate in the surgeries. I'm the attending's cameraman during the surgeries, and I also got to put a gallbladder into a sac before we removed it from the belly thru a small incision. Pretty cool. After that, we went over some info regarding colorectal cancer and other topics that would be on my oral exam. Then the attending taught me how to throw one-handed left knots, one-handed right knots, two-handed knots. I'm best with my one-handed left knots, but instrument tying is still stronger than hand thrown at the moment. I'm hoping to fix this before I throw another stitch on Thursday morning!

Some One-Handed Left Knots on a Vicryl Suture:

Sunday, August 28, 2011

Surgical AHEC: Day 1, 2, 3, 4, 5

Phew, what a week! I started my final rotation in surgery. It's away from my apartment, so I've been staying with my family near to where I am currently rotating. I am having a great time here...I follow the attending around, so I am there when he is there...which is not nearly as long as a resident is there. So, I've been working "normal" hours this whole week! Monday 9-3, Tuesday 7-1, Wednesday 8-3, Thursday 7-1, Friday 8-1. I am loving the extra time I get to spend actually studying or spending time with my family, not to mention the time I spend each day learning from the attending surgeon! It has been such a great experience so far. Oh, and did I mention that I get free, unlimited food from the hospital cafeteria!? SOooo I can work on gaining back some of those pounds I've lost from missing breakfast/lunch/dinner as a med student at the college of medicine's hospital...! ;)

Had a great weekend, too.. I'll try and fill you in after I finish my oral exams this Tuesday...which reminds me, I should probably start to prepare for those...! Ahhhh where has the time gone?!

Sunday, August 21, 2011

The "Golden Weekend"

I got to enjoy my very first "golden weekend"...it started from the moment I finished my on-call shift early Friday morning and it will end when I go into work early Monday morning...It's a resident's version of a normal working person's weekend - when you are off for an entire 48 hours straight! It is a very rare event, so they call it the "Golden Weekend".

So, what have I done with my Golden Weekend???... not much! Friday afternoon and evening was spent cleaning the house, cooking dinner, and laying out by the pool. Saturday we went for a walk at a park for a few hours, went to eat at a Mediterranean restaurant, then watched a film together, and today we went to the grocery, played a footy game, I studied and packed for my upcoming week away, and finally we went on another long walk. It sounds like a pretty average weekend, but you know what? I don't get these "normal" weekends often any more, so it felt amazing to be at home for so many hours straight. I even remember what it is like to have a boyfriend again! My house is clean, I got to walk my dog, my refrigerator is full, laundry is done, and I'm caught up on what's going on in my fiance's life...this has been the most successful weekend that I have had since I started third year! ...only in medicine would you highly anticipate and subsequently celebrate the mundane and average 2-day weekend at home!

At the Park with Mike & Marley:

Out to Eat at Byblos
 Kebab combo + Tabbouleh = yummmmmmmy
 ...what a gentleman, paying for my meal ;)

Saturday, August 20, 2011

Surgical Oncology: Day 15, 16, 17, 18

Apologies for not keeping up with the posts! It's been another busy week...I've been working my normal hours, plus had a presentation for Thursday, and did a 26-hour shift from Thursday 6a-Friday 8a. I've also been studying when I get home after work, as I have oral exams coming up soon as well as my shelf exam. Not an excuse, I'll try harder to keep up.

Tuesday: was in from 6a-6p. We were in the operating room all day, with a resection of the 3rd section of the liver, and then we removed 2 melanomas from a little old lady, one from her leg and one from her nose. After removing the spot from her nose, there was missing skin at her ala of the nose, so we did a rotational flap of skin to cover it. Pretty cool. I got to put an IV in, impressed that I got it in considering she was quite old and her veins were thin and it was also my very first one!

Wednesday was in from 6a-5p. We were in the clinic all day, which made it pretty enjoyable. After work, our attending took us out to eat at an Indian restaurant, which was really nice. I didn't get home until after 9:30, so I didn't get to spend any time with Mike before my on-call shift.

Thursday/Friday was in from 6a Thursday - 8a Friday. We were in the OR with a patient who had a large melanoma mole on his forehead. We excised that, then took the sentinal node in for frozen section. Deciding which node is the sentinal node can be done by injecting a radioactive dye into the main lesion, in this case it was into the forehead at the place of the melanoma. This dye will drain into the sentinal lymph node. We can find that node by either the color (if using a blue dye) or by the radioactivity via the use of a gamma probe. This patient had radioactive dye injected, so we got to use the gamma probe to find the sentinal node. We took that lymph node out, then went down to the frozen section room and looked at it though a microscope. We didn't find any suggestion of melanoma in the node, which means that it probably hasn't spread and we don't have to continue to dissect more lymph nodes out of his neck. Good news all around! It was hard to close the skin, as it was a big hole that we took out of his face, but we managed to do a rotational flap instead of a skin graft, and it turned out alright. I might also add the fact that this young man did not have insurance, and our attending was doing this surgery pro-bono. I love doctors that love their patients more than themselves - you'd be surprised by how few of them there are out there!

Got home on Friday morning, slept a few hours, then did some things around the house...went to the grocery & made a nice dinner on the grill before watching a film with Mike. It's nice to have a chilled-out night after a long week of work!!

Monday, August 15, 2011

Surgical Oncology: Day 13-14

Was in Saturday from 6-9:30, just doing rounds. My resident told me I didn't have to come in early when I was about to leave for the day...I could have slept in!! Shoulda told me sooner!! ;)

Today I was in from 6a-6p, and it was a full clinic day, which I love. I get to see so many different patients, and I am starting to feel more comfortable and relaxed with each encounter. I'm starting to enjoy sitting down and talking with the patient about his/her problem(s). It is so much fun to be able to give my advice on things, even if it's as simple as how to treat constipation and why each laxative is different, I am loving being able to give my opinions. I try to teach something to each patient...Since I learn so much from them, I think it's only fair to try and share some of my knowledge with them.

The types of patients I saw today include: Invasive breast cancer (invading the skin of the breast), colon cancer in a 50-something patient, carcinoid syndrome, liposarcoma, thyroid cancer, and a really REALLY rare case: a man with malignant pheochromocytoma of the organ of Zuckerkandl. The Organ of Zuckerkandl is a chromaffin body derived from embryonic neural crest tissue and is located at the bifurcation of the aorta at the origin of the inferior mesenteric artery. This little bit of tissue at the aortic bifurcation can become cancerous and release excess catecholamines into the blood stream. Catecholamines, such as Dopamine, Norepinephrine, and Epinephrine, are known as the "fight or flight hormones"...they cause increased heart rate, increased blood pressure, and increased blood glucose. In order to counter-act these effects, a patient is given an alpha-blocker, which blocks the alpha receptors from vasoconstricting, and thereby decreases the effects of the catecholamine release on blood pressure...In short, it keeps the blood pressure from rising too high. I palpated his umbilical region and felt the tumor; it was big enough to feel through the abdomen, even though the aorta is pretty much right on top of the spine. That was really cool. He's had this tumor for several years, and we are controlling its growth by inhibiting its ability to establish a bigger blood supply; We are suppressing angiogenesis ("growth of new blood vessels") by giving the patient a drug called Thalidomide. You might remember this drug in its relation to birth defects that it causes... It prevents the limb buds from developing fully, and children who were born to mothers who took thalidomide during pregnancy were born with deformed extremities...so we don't often see a patient on this drug, but it can still be very useful in certain situations (this patient is a great example).

Friday, August 12, 2011

Surgical Oncology: Day 12

In from 6a-3p: only a 9 hour shift, how lucky am I?!? We had resected a few lipomas from the armpit and underarm of an unfortunate young man, and then we did a thyroidectomy with central neck dissection. First thyroid case I've seen, it was cool. It's so strange to see someone's neck cut open! There are so many things to see in the neck, so many important vessels, nerves, organs, muscles, blood vessels are there (Carotid Artery, Jugular Vein, Vagus Nerve & its branches like the recurrent laryngeal nerve, the esophagus, the trachea, lots of muscles like the sternocleidomastoid, the STRAP muscles that help us swallow, etc.). The patient had Medullary Carcinoma of the Thyroid and also many wart-like/leprosy like growths called Neurofibromas all over the skin. So we suspected that the patient may have a MEN syndrome (Multiple Endocrine Neoplasias Syndrome), so we checked for a pheochromocytoma...which was found to be negative. We expected the patient to be in the MEN2b category...There are 3 classes of MEN: MEN1 (Pituitary Cancer, Pancreatic Endocrine Tumors, Parathyroid Cancer); MEN2a (Parathyroid Hyperplasia, Pheochromocytoma, Medullary Thyroid Carcinoma), and MEN2b (Medullary Thyroid Carcinoma, Pheochromocytoma, Neurofibromatosis). The incidence of MEN2b is 1 in 40,000, so it would have been somewhat rare to have had a patient with this particular syndrome. It was an interesting case none-the-less!

I'm in tomorrow morning for rounds and then I have the rest of the weekend off (THANK GOD!!!!). I need a break from it for a few days!!!!

Thursday, August 11, 2011

...Surgical Secrets

When people think about surgeries, people often consider many things. Imagine a surgical scene...I am guessing you are imagining a big cold room, white walls, blue linens, steel instruments, surgical caps covering the surgeon's hair, masks, gloves... And if you think hard enough, you may think of the anesthesiologist, a ventilator, big bright lights, ultrasound machine, xray machine, computers...But one thought that never crosses anyone's mind is how it will smell. But think about it...we use heat to cauterize arteries, heat to burn through fat, heat to transect things...naturally, it's going to smell like frying meat. But it's the most horrible frying smell, it almost makes me sick, like a sweet and smoky burning smell, it's horrible. And fat is the worst. It's strange that fat would smell so bad, since melted butter is one of my most favorite smells in the world, and nothing makes me drool more than a nice Ribeye Steak cooking on the BBQ. It's evolution, we're meant to crave high-calorie foods to store energy for times when food is scarce. But the smell in the OR is nauseating, it's horrible...In a way, the OR smells like a sketchy BBQ, like a really shady street meat vendor. Seriously. Today we used micro-wave ablation to transect a liver...we microwaved a human liver. What a smell. It was almost aromatic, but still it was a very bizarre smell. After not eating all day (I was stuck in the OR until 4), I can't say that I have any appetite tonight. And I can honestly say I will think twice before I again try any "Liver and Onions"! If I make it through the rest of my surgical clerkship without becoming a vegetarian, I'll be a little surprised. Yuck!

Surgical Oncology: Day 10-11

Yesterday was 6a-6:30p, today was 6a-5p.

Yesterday was another clinic day. I saw the craziest case of breast cancer...this woman has 3 nipples and 4 breasts. I was definitely a little excited to see such a rare case, but once I got in with the patient and examined her, I immediately felt concerned. One nipple had retracted and dimpled, giving a so-called "cauliflower appearance". Near to that nipple, there was a reddish, shiny, blanchable, and growing spot on her skin. Behind the red spot and the nipple, there was a large, hard, immobile lump. Just upon examination, I could tell it was going to be cancer. So a biopsy was done of the 2 areas (the red lesion and the lump), and we are awaiting the results. She was a person that did not go to a family doctor regularly, did not get annual exams. She also, having such irregular anatomy, did not know the signs of what is irregular but not harmful versus what is irregular and alarming. I will be following her until my time on the oncology service finishes; I hope things turn out better than we anticipate. The thing is, she knew that something was going on with her breasts, but it took her over a year to make an appointment with a physician to get it looked at professionally. I pray that it is not too late, we will definitely offer her every opportunity we have available to us, let's just hope that the treatments are successful.

Today, I watched a right hepatic lobectomy on a patient with metastatic carcinoid. Carcinoid is a type of tumor that secretes serotonin, and causes symptoms such as flushing and diarrhea to occur as a result of the excess serotonin secretion. This patient had the primary carcinoid in the small intestine; I had met another patient with carcinoid, which had its primary in the ileo-cecal junction. In medical school, carcinoid is synonymous with a tumor of the appendix, which is the most common tumor of the appendix, but is not the most common place for the primary carcinoid tumor to develop. Anyway, the patient had radioablation to the liver mets previously, as well as a slight resection. So when we went in to try and resect half the liver, we met a lot of fibrous scar tissue that was adherent to the liver capsule and overlying muscle, fascia, fat and skin...so it was really difficult to mobilize the liver. After several hours, we finally got the liver free from adhesions, we microwaved it to transect the liver, and pulled out the right lobe. This should prolong the patient's life and the quality of life (it should lower the symptoms), but it is not a cure. Luckily, carcinoid is fairly slow-growing, so the prolongation of life should be quite significant.

Tomorrow is another day in the OR from dawn til dusk...1 more week left of surgical oncology then its off to a new hospital for a few weeks!! :)

Tuesday, August 9, 2011

Surgical Oncology: Day 9

Was in 6a-6p. Pre-rounds, clinic, then watched a few surgeries. Nothing too crazy...

I saw a patient in the clinic today with cervical cancer that has spread through the rectum and all the way to her sacral skin...looking at her lower back, you can see straight through the rectum and into her body. It is really impressive. It was really, really hard to see her, slowly dying of her cancer that has been taking over her body for the last 10+ years... The attending had a piece of advice on how to deal with these situations...you can get angry, or you can get courageous. He decided to pursue a career dealing with oncology because a friend of his was taken by cancer at a young age, and he got angry and wanted to change things...This also brings me to a sidetrack point, which is the importance of preventative vaccination. If you haven't gotten Gardisil (the HPV vaccine now approved for girls AND boys), you should strongly consider getting it. The risks are negligible, and the benefit may be insurmountable.

I'm in the clinic all day tomorrow, so much better than the OR!!! :)

Monday, August 8, 2011

Surgical Oncology: Day 7-8

Was in on Saturday night-sunday morning from 6p-6a. Today I was in from 6a-6:30p (we were in clinic all day). We actually talked about Lynch Syndrome again, this time at the tumor board meeting...there are differing views about prophylactic colectomy, and about the necessity of doing genetic testing. Nothing new that I haven't heard before, but its always nice to hear it mentioned! :)

Nothing very exciting happened today.

Yesterday, a cute little old lady looked at my ring while I was doing a physical exam, and she asked me if the lucky man was a doctor..I said no, I know better than to marry a man I'd never see! And she said "Don't marry a doctor...you're a smart girl!" She actually was the wife of one of the best surgeon's ever to serve this area...so I guess she knows her stuff!  ;) I'm pretty happy about the man I chose, but I love to hear people remind me of my good fortune!

Saturday, August 6, 2011

Surgical Oncology: Day 6

I came into the hospital today and did pre-rounds from 6a-830a, and I am working tonight 6p-6a (on call). So I packed my toothbrush and things, expecting to be in from 6a-6a...Much to my surprise, my chief resident told me I could go home at 8:30! Suddenly I had something like a day off (well only 9.5 hours, but that's a lot of time away from the hospital after a full, already 70 hour, week!). So Mike & I went car shopping (more like car browsing), then we came home and I took a short nap and studied while Mike watched the Liverpool game and then went to play a footy game with some of his mates. I could really use more days like this!haha :)

The Whipple Procedure which I spoke about previously was the first case I scrubbed in on in this rotation. It is done to treat pancreatic cancer. The 12+ hour surgery entails removing the antrum of the stomach, the 1st/2nd parts of the duodenum + proximal jejunum & associated lymph nodes, removing the head of the pancreas (or more if the cancer is in the body or approaching the tail - if you remove the whole thing you must also remove the spleen, as its blood supply runs thru the pancreatic tail), removing the common bile duct and the gallbladder. So it is a fairly extensive surgery. It is also a fairly rare surgery; its indications for use include localized/non-metastasized pancreatic cancer, and rarely for palliative care for pancreatic cancer patients. The reason it is so rare is not because pancreatic cancer is rare, but because pancreatic cancer often grows unnoticed until it is too far along to treat. This helps explain why pancreatic cancer, although it is only the tenth most common cancer, it is ranked as the fourth leading cause of cancer deaths. In lucky patients, there are noticeable signs/symptoms if the cancer is at the pancreatic head, which obstructs the common bile duct, and leads to "painless jaundice" - a yellow color to the skin and sclera without any pain around the liver. In such patients, we may be able catch the cancer before it has had a chance to spread, and we opt to perform a whipple procedure to try and cure the patient. I know of one lucky man that survived pancreatic cancer for many years thanks to a successful Whipple (a patient at the nursing home where I used to work). After removing the antrum of the stomach, a portion of the duodenum and jejunum, and part of the pancreas, we found a hard nodule behind the portal vein as well as behind the superior mesenteric vein, which we presumed to be cancerous and completely unresectable. So about 7 hours into the procedure, we realized that this procedure will more than likely prove to be unsuccessful, and the patient's prognosis is very poor...If those nodules were in fact mets from the pancreatic cancer, the average patient can expect a 3-6 month survival. When we realized that the procedure was not to be a success, I really didn't want to be in the OR anymore. It felt like such a failure...but I can try to be optimistic and think that the nodules might have been scar tissue from radiation, not a met, in which case she will have been cured from the disease. Only time will tell...

On a brighter note, I thought I would share some photos of our Saturday River Time from last week! We went with 4 of our friends, and had another really great time out on the water. I just love summer time!!! :)

Me on the Water

 Mike loves to fish

...and he caught some seaweed...twice! ;)

I suppose its time to get back to the hospital - I have lives to save, you know!!! (or more like foley catheters to put in, IVs to place, and H&Ps to perform...). Hope everyone is having a great weekend :) :) :)

Friday, August 5, 2011

Surgical Oncology: Day 5

In from 6a-6p today. Did prerounds then watched a right hemicolectomy from 9-1230 then watched two breast lumpectomies plus sentinel lymph node and axillary lymph node dissection unilateral 6. The first patient had colon cancer so I of course had a strong interest in the case. I even transected the jejunum and colon and anastomosed the stumps back together. Pretty cool! I also stapled the patient's abdomen at the end of the procedure and placed the wound vac. Was fun!! Regarding the breast lumpectomies, I definitely would just get rid of my breast completely rather than a lumpectomy so that my odds of recurrence are the lowest, they are just boobs. Nothing I need right? But our society bases a definition of a woman on her breasts... so we do lumpectomies to conserve boobs instead of lives. The stats are something like: society dictates that 88 breasts are more important than saving 4 lives...

I want to unload all of my whipple experience on to here, but I'm still tired and tomorrow will be a 24 hour shift. Is surgery over yet?!?....

Thursday, August 4, 2011

Surgical Oncology: Day 4

I was in the OR on one procedure for 11 hours today, so I'll make this short! It was a whipple procedure, which is a pancreatoduodenojejunostomy plus a few extra touches. I want to write everything out that I saw and learned today, but 14 hours of standing with my arms above my belly button but below my nipples to stay sterile during the procedure made me tired... Yes I was scrubbed in for a relatively rare and famous surgery- I was even allowed to transact the jejunum three times! Which was really cool. Anyway I'm off to bed I'll explain more tomorrow hopefully!!!!

Wednesday, August 3, 2011

Surgical Oncology: Day 3

In from 6a-6p. Did pre-rounds, then went to the M&M (Morbidity & Mortality) conference until 9, then I was in the clinic all day. It's fun to see the patients, but I don't like how quick the interaction is. The attending knows all about the patients that come in to the clinic, so he doesn't need to spend the time to learn about the patient, but they are all new to me...so I wish I could spend a bit more time with them, getting to know the process and the disease and treatments/managements.

I saw a patient that had a strange cohort of cancers in her family, things that don't typically go together. If a patient has a family history of several different types of cancers, you might suspect a p53 mutation (a tumor suppressor gene), which can give rise to any uncontrolled cellular growth. Alternatively, you might suspect HNPCC, since there are a variety of cancers associated with this syndrome. Yes, a physician actually knew about HNPCC, and even gave us a little review about it. I was thrilled! Granted he is a surgical oncologist, but the fact that he knows so much about the syndrome makes me really happy. Hopefully he spreads his knowledge to all of the students he sees... He even asked us a question about HNPCC, which another girl on my service answered before the question was even finished, so even though its one thing I know a whole heck of a lot about, I couldn't even impress my attending with my knowledge. What a waste. Hopefully I'll get another chance to really impress him, but I think I'm doing alright so far. My work ethic is high, and I keep a smile on my face along with a "glad to help in any way" attitude, so I think I'm doing ok so far!

5 weeks of chronic sleep deprivation is starting to really catch up with me. I hate to say this, but I am tired. All the time. There needs to be a way to add a few more hours to each day, or a way to effectively live off of only a few hours of sleep. And my next day to sleep in will be NEXT Saturday. So I guess it's off to bed for me - it's only 8:30: oh the exciting life of a third year student on surgery clerkship!!!

Tuesday, August 2, 2011

Surgical Oncology: Day 2

Was in from 6a-6:30p today...I literally just got home. Rounds, clinic, lunch, then in the OR the rest of the day. I watched the second half of the Ivor Lewis Esophagectomy on a patient with gastric/esophageal cancer, originating at the GE junction. This surgery takes about 9 hours from incision to final suture. The patient was put in the lateral decubitus position (laying on his side), and the right thoracic cavity was opened, and I could see the stomach, diaphragm, heart, esophagus...today was the first day that I have seen them, up close and personal, in a living, breathing patient. It was really humbling. We were thankfully let go before the last surgery began...it will take about 4-5 hours to complete, so I would have been there until at least 10p if the chief resident hadn't let me go.

I love medicine, but I am starting to get a little sick of surgery (and I've only been in the OR about 6 times!). I love seeing patients, talking with them, deciding their treatment and management, and treating the patient as a whole person. Saying that, I heard from a few classmates that Peds can be a real handful, especially when the parents have no idea how to be parents. But I'll find out all about that before long! :)

Quote of the day: The attending was talking about how to handle patients who are losing their battle with cancer, and he alluded to the fact that it is human nature to try and stray away from people we know will be leaving us before long. It's emotionally taxing to deal with the loss of friends, so it is only natural for us to shy away from becoming too friendly or involved. It hurts to lose a friend, a patient. But, he insisted that it is far more important to offer love and compassion to our patients, no matter how difficult it makes life for us, no matter how emotionally draining. A patient who is terminally ill needs love and compassion more than ever, and we need to give it to them, even if we sacrifice our emotional stability in the process. I'm happy to hear a surgeon say that...we have some very caring physicians in our hospital. I'm glad to be a part of that.

Monday, August 1, 2011

Surgical Oncology: Day 1

Today was my first day on Surgical Oncology...was in from 6a-530p. Did some pre-rounds, made my own SOAP notes (not with a template, but my very own notes!), and visited my patients. One had an abscess in the abdomen, another had a cholecystectomy, and I was following their progress post-operatively, with the goal of discharging them home. From 8-9a, my partners and I had an educational meeting with an attending...we went over the basics of shock (for like the 100th time), and also the clinical importance and relevance of respiratory or metabolic alkalosis or acidosis. Then I was in clinic for the rest of the day (9a-5p), and finished up with a quick round on our patients. I saw a lot of cancer patients, a lot of diagnoses, and a lot of age ranges. I quite like oncology...but I think it takes a special kind of person to deal with that day-in and day-out and maintaining hope and optimism and without becoming a lunatic. It can't be easy to see the ultimate prognosis of so many patients...despite our very best efforts and the best medicine can give them, so many will succumb to their illness - some in a year, some in a decade, some in their later years.

Tomorrow, I will be in clinic and then I will get to possibly see a Whipple procedure! Here's to the start of my time in the OR!!! It's going to be a great 3 weeks of surgical oncology!!! :)

Quote of the day from an attending: "So your fiance went from Liverpool to Toledo...really moving down in the world! I know you're a nice girl, but no one can be worth that!" haha  ...but I guess I am! ;)

Trauma Surgery: Day 18

My last day on Trauma Surgery was Sunday! I was in just for rounds, so I worked from 6a-12p. Best.hours.ever! Just visited my patients and wrote their progress notes then rounded with the attending. I am going to miss it. I definitely like that I chose to do Trauma first. The quick action in the trauma bay in the emergency room really helps you pick up on what's most important. I have had a lot of attendings ask me questions about what to do in an emergency, and, because of trauma, I feel prepared. I would definitely recommend it to others; the hours are long (you never get out early cause you never know when there could be a new trauma admit!), but when a trauma case is admitted, it's the one patient that the whole hospital is talking about, and you get to be in on the action. I'll keep up with my patients until they are discharged...I have a feeling long-term care is the type of field I want to go in to, because I want to follow-up and know how all of my patients are. I suppose surgeons do this with their clinics, but I don't know if that would be enough for me...I like to treat the patient as a whole, not as an exclusive part (like "i'll be dealing with your trauma, he'll deal with your heart, and she'll deal with that mass we found on the CT").

I'll be happy not to see anymore massive head injuries from motorcycles, though...Good Riddance!! :)