Neurology Week 2

Monday, October 1, 2007
This week I’m working in the clinics. Clinics are kind of a painfully boring process, because we don’t actually DO anything. Instead, we just watch the doctors do stuff. It wouldn’t be such a big deal except at this point in my education, I feel like I’ve been “watching” forever and really relish the opportunity to take some action. Oh well.

This morning I am in the neuromuscular clinic. It’s not very busy. Our first patient is a lady with fasciculoscapulohumoral dystrophy. Try saying that 20 times quickly. It’s interesting because, if I had just seen her out on the street walking around, I don’t think I would have noticed that there was anything wrong with her. I would have just thought that she didn’t move her arms very much when she walked. She’s actually in pretty good health. So it’s a quick visit.

Our next patient is a very pretty 24 year old girl named A.S. A.S. is coming in because she has felt weak all over… for 7 years… ??? Her symptoms are really weird. And I think both the jr and sr doctor that are involved in her case think that she’s nuts. I get the feeling from listening to them talk that they often think that their patients are nuts. We do a full exam and then decide to do something called electromyelography (EMG). An EMG is where they attach all of these electrodes to different parts of your body, and then measure how well your muscles respond to your nerves getting stimulated. It’s kind of unpleasant. But the worst part is, they also stick needles into the muscle as well. She tolerates it well… and everything comes back negative. It’s a really weird situation. She’s really pretty… she seems really nice… she seems genuinely worried about her health… and yet… there is something about her that’s just not right… and you really do get the sense that she might be a little nuts… I try to keep my distance from her, because there’s one thing you learn very quickly when you’re a male medical student… Pretty female patient + kind of nuts = BIG TROUBLE.

But on my way out to lunch, I run into her everywhere! Yipes.

In the afternoon, I’m with my Chief Resident, which is very cool, because I really enjoy working with him. We have a really interesting case that comes in. It’s a Mr. B.W. He comes in after going to a bunch of doctors somewhere south of Richmond. He apparently was at home over the summer and had a seizure that no one else saw. But after that, he started having this weird series of tremors. We do all of these neurological tests… and the thing is… it’s pretty obvious that he’s faking… okay… maybe faking isn’t quite the right word for it… but it’s obvious that his tremor is probably caused by a psychological cause. This isn’t unusual. It’s something called conversion disorder. Sometimes, when you’re dealing with a psychological or emotional stress that’s too intense to handle, your body turns it into physical symptom.

In Mr. B.W.’s case, I spend some time talking to him and his wife… and I am able to piece it all together. It turns out… in the spring, their 9 year old daughter passed away. She was mentally delayed with cerebral palsy, which means she had a lot of developmental issues and a lot of medical issues. Taking care of a child with complicated health is an all-consuming job. When the child dies… it leaves a huge void that is really difficult to fill. Suddenly, the parents find themselves having to relate to each other with all of this time suddenly emptied from their normal routine. It is a huge stressor. Many couples do not make it through this and end up getting divorced. In the case of Mr. B.W. and his wife… his body turned this stress into a visible physical disability that brought him and his wife back together. She worked with him in a very obvious maternal way. She took care of his every need. She helped feed him. She helped bathe him. But his symptoms… if you wrote down the symptoms that he felt he was having… you would read about and think… “Textbook case of Parkinson’s Disease.” The only problem is… when you test his reflexes… when you test his tremors… they are very clearly “controllable.” That is to say… you can do things to make them go away… in a way that is physically impossible with an actual neurological condition. So why would this guy’s subconscious pick Parkinson’s Disease of all things? After talking to him… I found out that his grandfather had Parkinson’s. And he used to take his grandfather to the doctor all of the time.

I felt like a rockstar for figuring this out. Seriously. I can’t remember the last time I had so much satisfaction in deciphering what was going on with someone. When I present the situation to my Chief, he is ridiculously impressed. He pats me on the arm and says, “very nice, man… very nice.” But the problem is… how do we help him? He’s not deliberately faking this… And you can’t very well say to him… “Dude… it’s all in your head.” I was at a complete loss. When we presented to the attending, he was skeptical of our diagnosis until he actually went in and physically examined him. At the end of the physical exam, he sat down with Mr. and Mrs. B.W. and said, “Well, I’ve seen a lot of different movement disorders in my life… and this doesn’t fit any patterns that I have seen… I can tell you with 100% certainty that you do NOT have Parkinson’s. I should tell you, that there are many psychological conditions that can cause these kinds of physical symptoms.” As he said this, I was thinking to myself… that’s about as smooth a way to discuss this as I could possibly imagine. However… this did not go over well. This did not go over well at all. There was some serious frustration and anger coming from the couple. And in my head… I couldn’t figure out how else this situation could or should have been handled. In the end, our attending offers them some tests that can maybe be more definitive and I think that was a smart idea. Offering them the option to look at objective data to rule certain things out is probably the best thing to do.

Thursday, October 4, 2007
Tuesday and Wednesday were gigantic wastes of time. We didn’t really see many patients, and the ones we did see were basically there for follow-up appts. Most of the time we were there, we had to listen to this Dr. talk on and on and on about stuff that none of us cared about. Like his dream car… like how much school cost when he was a student… the guy had the worst case of diarrhea of the mouth I have ever encountered. And it DROVE ME CRAZY.

Today, I am in boredom hell. We are in something called EMG clinic. Like I said before, EMG stands for Electromyelography. It’s a really boring procedure, where they zap a series of nerves to see how well your nerves are working. It’s painfully boring to watch. Imagine watching someone press a button that causes squiggly lines to form on a computer screen. Imagine them doing this like 100 times for an hour. Yes. Very boring.

We sit through a couple of these when we get a gentleman named Mr. C.W. come in. I look at his chart and I realize that he has the exact same birthday as my dad. He is here to get his nerves checked, because he has a type of cancer called Multiple Myeloma. It’s a cancer of a type of white blood cell that often occurs in older adults. It’s pretty easy to treat if it’s caught early enough. Treatment is with a drug called Thalidomide. Thalidomide is a drug that was once used to help pregnant women with morning sickness… until they discovered that it created HORRIBLE birth defects in babies. It often caused children to be born with less than fully grown in arms and/or legs. It stopped being used at all for a while, but now is used to treat leprosy and multiple myeloma. The only problem… it can cause permanent nerve damage.

So we get ready to run the EMG on Mr. C.W. who has been on Thalidomide for his Multiple Myeloma… except he needs help getting his shirt off because he can’t move his fingers anymore. As I do so, I tell him that he has the same birthday as my Dad. He asks me, “Same year and everything?” When I tell him, yes, he replies, “They made them good back then.” I laugh and I say, “Yes, sir… not soft like they do, now.” He gets a good laugh out of this. Then we do the EMG. And it’s awful. He has significant nerve damage. And it’s permanent… even if he never took another dose of thalidomide again.

I help Mr. C.W. get his shirt back on. As he walks out, he says, “Tell your Dad I said hello.” I thank him. And as I see him walk out to get his wife so that they can hear the news together, I am grateful that my Dad is healthy.

Neurology sucks.

Friday, October 5, 2007
It’s my last day of clinic.

The morning is boring and uneventful. In the afternoon, I have Resident Clinic. I am with a Resident that I have already figured out is pretty awful. I go in to see a Ms. L.L. who had previously had seizures and was taken to the hospital. The Neurology service had figured out that she had probably had a seizure because she was in severe liver failure, but we’re following up on things with her in clinic.

When I go in to see her, she is this really nice old lady who is there with her adult daughter. I talk to her about her seizure and then talk to her about her liver failure. It turns out this nice, sweet old lady used to do drugs. She shared a needle with someone and ended up getting Hepatitis C. With her Hepatitis C, she developed cirrhosis of the liver, which is basically where the liver gets so scarred up that it causes liver failure. This ended up turning into liver cancer. She is now trying to get on the Transplant list. It’s a really amazing interview and the physical exam goes smoothly.

Then I go to talk to the Resident. He bounces from room to phone to room to phone. It takes him an hour after I left the room to go back in with me. Once we get in the room, he talks to her for about 10 minutes, when his pager goes off. Then he does the most amazing thing. He picks up the phone in the room and returns the page. He sits down and he talks on the phone… for 25 minutes. I looked at my watch and kept track of the time. 25 freakin’ minutes. I couldn’t believe it. The crazy thing is… it was very clearly NOT that important. He spent about 2 minutes talking about important stuff… and then started going off on a series of other VERY UNIMPORTANT tangents. The mother and daughter are staring at the ground… very obviously uncomfortable… very obviously unhappy. I AM FURIOUS. How could he do this to her? I start trying to figure out what the heck I should do. Do I leave in disgust? Do I stay? I hate this more than anything I have ever had to deal with. Finally… I take out a sheet of paper. I write on the paper, “I’m sorry for him,” and hand it to the daughter. She smiles and writes down, “It’s not your fault… but thank you.” He finally gets off the phone… and he does a quick exam… and then he leaves… the daughter shows the note to Ms. L.L…. and Ms. L.L. touches my hand and says thank you.

This is the one thing I had always worried about coming into 3^rd year. I knew that I would run into situations where I was going to have a better rapport with my patients then my supervisor. What I didn’t anticipate was running into a situation where my supervisor was going to be so blatantly unprofessional in front of me.

Being on Neurology is so much easier in many ways than Surgery ever was. But there's a lot about it that sucks in a major way. I'll be glad when it's done.

Neurology Week 1

Monday, September 24, 2007

It’s Monday morning. My first day on my new rotation, Neurology. Neurology is the study of the Nervous system, for example, the brain, the spinal cord, and nerves. It’s one of those things that I think is really interesting and fascinating… but really hate to study. It’s really a complicated mess trying to understand how everything works.

So I’m not exactly EXCITED to start Neurology. But I know that the hours are better and I’m looking forward to having a little bit of a break in terms of workload.

We start off the day with Orientation. It’s really quite painfully boring. We get handed about 20 sheets of paper. And the girl that is leading our orientation is somewhat new. So she doesn’t really seem to know what she’s talking about.

We then have one of the Residents come in and talk to us about a typical neurological exam. It is awful. She is describing every single step of it in boring, monotone detail. And I want to stab myself. It is a struggle to stay awake. Even with 20 oz of Starbucks coursing through my vein. I think I may have to upgrade to crack.

When we are done with orientation, we get 3 hours off until we have to report to our service! Okay. So maybe I’m kind of liking Neurology at this point. It’s funny to see the faces of people just coming off of surgery. The minute they get anything resembling a break, they get giddy. We were walking around looking at each just grinning from ear to ear.

At 1 p.m., we reported to our floor. I’m on Consults this week. This means when a patient is in the hospital and their doctors think they need to be examined for a possible neurological problem, they call us and we go look at the patient. It’s kind of interesting, because a lot of times it’s basically elaborate puzzle solving. I go on the first consult which is actually on the Psych floor. I’m not actually running this one, I’m just going to watch. This one is being done by our 4^th year medical student who is going to be going into Neurology, so is doing a Neurology Acting Internship (AI).

It’s really interesting. We are seeing a patient who has been admitted to the psychology floor. We are examining her for possible seizures. She tells her story… and there’s just something not right about it. And it doesn’t fit what others are saying about it either. She also tells us that she has a disorder called acute intermittent porphyria (AIP), which is a disorder of the blood, where your body is missing certain enzymes for producing hemoglobin. This disorder can actually cause some psychiatric issues. The problem is… she has several other psychiatric problems… including hallucinations. Apparently she goes into these spells where she is going into a deep hallucination… but she also continuous hallucinations throughout the day. So it’s really hard to figure out what exactly is going on with her. If this sounds confusing, it’s because it really really is. I am trying really hard to figure out some idea of how this story fits… and I am completely at a loss.

When we are done with taking the history and the physical exam, we walk outside and our AI asks me what I think. And I tell him, I don’t know… but I kept having the feeling that she was faking at least part of the story or the symptoms. My AI says, yup. And he tells me about different parts of the exam that he did to kind of see if she were faking. There are some things that she said she felt during the physical exam that just aren’t possible. I thought that was pretty cool. We find out later that she doesn’t even have AIP. We also find out that the nurse saw her during her so-called seizure… and says it was nothing like a seizure at all. Plus, in addition to her so-called seizures… she also sees people around her all of the time. Imaginary people. These people, she says, will walk through walls or will be cutting up other people. She also says, she sees the floor opening up and sees herself getting sucked into it. Pretty interesting. We still have to go through an entire physical workup just to make sure. But after ordering all of the tests, they let us go home. Not a bad first day.

Tuesday, September 25, 2007

My morning starts off interesting. In the middle of rounds, we get a page for a possible stroke patient in the ER. I go down with one of the senior residents to see Mr. NB. We find out that he’s been this way for a couple of days, so if it’s a stroke, it isn’t a new one. He is definitely confused. His eyes seem to want to stare off to the left. He also appears to be blind, and is not making sense. One thing for certain though… he is not well. On top of that, he is really angry and is resisting anything anyone wants to do to him. After we do a full neuro exam on him, my job becomes sorting through his medication. It is literally… a box… filled with about 60 bottles. Many of them are the same medication, but it takes about 15 minutes trying to sort it all out. At the end of it all… we have NO idea what’s wrong with him. I think Neurology is like this… it’s amazing what we can tell about what’s going on inside the body simply by physical exam… but there are also many times where we just can’t figure out what’s going on with them.

He also has some serious problems with his kidneys. I kind of feel like we’re trying to untangle a big mess of Christmas lights…. It’s just so hard to figure out where to start.

Working Mr. NB up takes the entire morning. In the afternoon, we have some instruction time in a lecture hall and we learn how to do lumbar punctures aka spinal taps.

I’m home by 4:30. When I get home, I find an email from my friend and brother, Justin at Virginia Tech. He has a friend with some puzzling symptoms and he wants my opinion. And I get excited. See his friend has a disorder that is pretty unusual. And for the most part… there’s no real reason why I should know it. But last year, my FCM small group instructor came in and told us about a really interesting case that she had in the ER. And it was a condition that was a variation of what Justin’s friend had. While talking about the case, my small group instructor talked about some variations of it. So the minute Justin described his friend’s case… I knew what it was. I felt so smart… but really… it’s just about being blessed with some great experiences. It’s like I always say… there really is no such thing as “a waste of time.” You never know how a certain experience is going to be useful.

Wednesday, September 26, 2007

During rounds today, I witnessed an interesting thing. We were going to see a 54 year old man named Mr. JA. Mr. JA was celebrating his birthday in the typical way… party, cake, booze, pot, and cocaine. At some point, he became confused and appeared to have what we describe as “altered mental status.” This means that there appears to be something not right about him from a mental standpoint. It can be due to a lot of things, but they usually call in a neurology consult for these things. He had a history of strokes in the past, so the ER docs were worried that he might have had a small stroke. I’m thinking it might have had a lot to do with the booze, pot, and cocaine. But I’m just a medical student. What do I know. When we go to check on him during rounds, we see this old frail looking man. I can’t imagine him doing pot and coke. He starts talking about when he had a spinal tap. And he says that he is still traumatized by it to this day. And as he talks about it, he asks our attending, why the doctor who did his spinal tap did that to him. And things start getting really weird. He starts asking the attending over and over again, “why did that doc do me like that?” And an interesting thing happened. This frail old man, started getting kind of fierce… and intense… and all of a sudden… I found myself kind of afraid of him… it was unreal. Our attending does a great job of playing all of this off in a nice easy going way… but things have taken a weird turn, and there’s no going back. During the neuro exam, one of the things that we check for is muscle strength. And when our attending asks Mr. JA to put his arms up, Mr. JA asks him, “you sure you ready for that?” and gives him one of the scariest looks I’ve ever seen. As our attending tests his strength, Mr. JA takes a swing at him. It’s not a very good swing, and our attending doesn’t have to do much to avoid getting hit. But he immediately says, “okay, we’re done,” and we leave.

The thing that really amazed me about the experience was how quickly Mr. JA went from being a sweet looking frail old man to a fierce and intimidating man. It just goes to show… you can never really know what you’re getting into sometimes. You always need to be on your toes. Plus… you can never tell what a person is like based on their outer appearance. The nicest person in the world may have a tough shell… whereas a mean and dark personality may be masked by a smiling face.

Later that day, we get a request for a consult and it’s my turn to do one on my own. My patient is a Mr. JK who was in his house and collapsed. No one knows exactly what happened. He’s not really fully conscious, but he’s also not really with it either. I go to the ICU to examine him. This is really the first time I have ever gone in to see a patient who I couldn’t talk to. It’s… a challenge… I didn’t think it was a big deal when I went down… and in some ways you would think that the physical exam is easier, because they can’t see you mess up or be clumsy. But it’s actually really awkward trying to move around all of the tubing and stuff. It’s hard to really know if you’re doing the right thing. And when I’m done… I have no idea what the heck is wrong with him.

As I sit at the nurse’s station trying to figure out what the heck I saw, his nurse comes up to me and we talk… and she asks me what I think… I laugh and I say, “You’re kidding, right?” But she says I look like I know what I’m doing. It’s flattering… but pretty misguided. The interesting thing is when I examine his chest, I see old surgical scars… and I recognize the scars right away… he had a CABG! I tell my intern that and he asks me how I know it wasn’t just some heart surgery and I point to some different scars on his chest and then I show him the scars on his thigh. There’s just no substitute for actually having been involved in one of these surgeries.

I start to just think of all of the possible scenarios. One of the tricky things about Mr. JK’s exam is that he is on some medication that puts your nervous system to sleep. So I can’t tell if he has some problems with his nervous system or if it’s the medication. The nurse asks me if I want her to stop the IV for a little while. I’m amazed at how much this scares the crap out of me. I laugh and I tell her that it’s probably a really good idea that she has, but that as a student, I am way too scared out of my mind to decide that. She laughs with me, and I tell her I’ll check with my chief.

When I present the patient to my chief, I am surprised at how confident I sound. It’s weird how just being in the hospital for a few months starts changing the way you carry yourself. You almost become smarter in ways that you can’t begin to see or feel. He agrees with me and we tell the nurse to hold his IV medication for a little bit. We then go down together and do a full exam on him. He teaches me a ton about how to describe what I am seeing. It’s really refreshing having a Chief that is actually interested in teaching. When I show him how I know he had a CABG, he seems really impressed.

I go home at 4 p.m. Today was about as good a day as you could ask for.

Thursday, September 27, 2007

Before rounds get started, I go to see Mr. JK. It’s cool, because I walk into the ICU and he has the same nurse. She comes up to me and we start talking about him. It’s so weird to be in this position, where an ICU nurse with all of this experience is deferring to my knowledge and asking me my opinion. I’m not used to being in this position. I try not to act like a tool. I also try not to act like a total idiot either. I know more than I think. I am aware of this.

Mr. JK is definitely more awake. I’m able to talk to him a little bit. As I try to find out more of his story, I find that it’s tricky… because he really fades in and out. As I’m checking whether or not he has feeling at different parts of his body, I get the feeling that he may not be answering completely honestly… not that I think he’s lying… I just think he’s still too groggy to give me real answers. So I do some stuff where I’m not really touching him, but I ask him if he can feel me touching him. He says he can… So I know he can’t really tell… I feel a little devious… but I also feel really clever.

I present him on rounds and I go through my assessment and plan… which is where we say what we think is going on and what we want to do. Basically, I want to do several tests on him to rule out some simple stuff that we might be able to fix quickly, but I’m leaning more towards, some sort of fainting spell because of his cardiac issues, a seizure, or a mini-stroke. When we go see Mr. JK, our attending does a full exam. And he agrees with my assessment and plan. He also adds a couple more while we’re there. It’s a great feeling. His nurse comes up to me and we’re chatting and I let her know what we’re going to do. I guess I have to start getting used to being the one that gets asked about the plan… it’s an interesting feeling. Honestly, it’s incredibly flattering… and yet… it’s really scary. It’s a lot like the first time you ride a roller coaster… you’re scared the entire time, but you’re also really excited. I wonder if every 3^rd year medical student feels like this or if this is just my own special kind of goofiness…

After lunch, we don’t have much going on, so I go to study at the Medical Student Study/Computer Lounge called CBIL. While I’m there, I see a girl making photocopies. And I see the stuff she’s copying… and I recognize the material as being the graduate school stuff I had to do to get into medical school. So I ask her if she’s in the certificate program. She laughs and says, yes! I talk to her a little bit about the certificate program and the pros and cons. And I offer up some words of advice and some words of encouragement. It’s a little thing… but I love the feeling you get when you are able to help someone who is walking through a patch that you have walked before.

I’m on call tonight. I’m not really sure what to expect. So after studying at CBIL, I change into scrubs and then go up to the Team Room. I run into one of the residents on call and he tells us to go to the ER because there is a lady that we were just called about with ALS. ALS stands for Amyotrophic Lateral Sclerosis and is also known as Lou Gehrig’s Disease. It is a disease where your nerves that control muscle movement start to die. It’s one of those diseases that you hear about in medicine all of the time, but I have never seen a patient with it. As I go down to the ER with the other student on call, I get pretty excited to think I’m going to get to see this disease in an actual person.

When I get to the ER, the patient is a 79 year old woman named Ms. VT. She is this really sweet, really nice old woman who is there with her 45 year old son. After a minute of being in the room with her, I feel awful. She is here, because her ALS has gotten to the point where she is unable to talk or swallow. She’s here because we need to do something for her so that she can get some kind of nutrition in her. Her muscles for swallowing don’t work anymore. And the only way we know this is because her son is there to speak for her. I feel like a jerk. The world’s biggest jerk. Here I was… just 5 minutes ago… walking down to the ER… “excited” to see ALS. But in reality… I never once thought about what ALS does to someone… and right there in front of me… was the kindest, sweetest old lady in the world… with the nicest and most patient son… and realizing that this disease slowly takes away your ability to do any of the things that you take for granted. How must she feel… being completely alert and mentally together… and yet… unable to talk because her tongue won’t move. Fully aware of how thirsty and hungry she is… but unable to eat or drink because she can’t even get her throat to swallow for her. Wow. How “exciting.” ALS has just moved to the top of my list of diseases I hope I never get.

We spend some time talking with them. And I can’t help but just hold her hand. What an awful disease for anyone to have. And the thing is… there is NOTHING we can do about it.

When our Resident comes down to talk to them, it is painful to watch. He is a really nice guy and he is incredibly smart. But he is from a different country and he doesn’t really know how to ask questions in a way that a non-medical person can answer. For example, he asks her if she’s noticed any fasciculations. ????? He asks her if she’s noticed any wasting. ????? He asks her if she’s noticed herself laughing or crying inappropriately. ???????????? How does someone answer a question like that? The whole time, she looks at me (because even though she can’t talk, she can hear perfectly well) and has this expression on her face like, what the hell did he ask? I do my best to translate. It’s not easy.

When our resident does the physical exam, he shows us a lot of the specific physical findings that are unique to someone with ALS. It’s a really good learning experience. But I still feel guilty about learning it at the expense of Ms. VT actually having the disease. I would give anything for her to not have this.

When we’re done, we decide to put a tube down her nose, down her throat, and into her stomach, so that we can start some nutrition on her. Later on, she will get a feeding placed surgically. Her case makes me incredibly sad and I have a hard time shaking it.

I go to the call room. When we’re on call, we’re not alone. We’re usually on call with people who are on other rotations. Two of my friends on Psych rotations are on call. We decide to go to McDonald’s and get ice cream before they close. On our way down there, we get in line and all of a sudden their pagers go off… but not mine. I wave goodbye to them… and very happily order my Oreo McFlurry. It’s the best tasting McFlurry I’ve had in a long time. Why does it taste so sweet when others get paged and I don’t? I guess I’ll never know.

I don’t get paged at all over night. My other Neuro friend gets paged at 5 a.m. Hee Hee Hee.

Friday, September 28, 2007

After waking up from being on call, I get some breakfast and go to evaluate Mr. JK. He’s been moved out of the ICU which is a good thing. He’s on a regular medical floor. I go to see him… and I am amazed at how good he looks. He is much more alert and he remembers me and he remembers that I have been coming in to see him. For the first time, he knows the date correctly. I get a little bit more detail about what happened to him. And it sounds like he fainted and/or had a little seizure. This would explain why he was so confused for 2 days. He’s doing a ton better and I am very happy.

At rounds, our attending looks at me and asks me if I was on call. I tell him yes. He tells me to present my patients and present whatever topic I was supposed to teach everyone about and then go home. I’m out of there by 9:30. How perfect!

So I’ve finished my first week of Neurology. The hours are a million times better than anything I had on surgery. It’s a little boring at this point. But I love the fact that I go to work like everyone else in the world, I eat lunch at lunch time every day, and I get home before normal dinner time.

Seeing that girl in the Certificate program was good for me. It was another reminder of where I was… and made me appreciate where I am now…

I kind of feel like I was in an episode of “House” this week. Only, the ending wasn’t as satisfying as the TV show. Plus… and this is important… the diseases suck a lot more and in reality… there’s so much less that we can actually do for people.

Surgery Week 7 & 8

Surgery Week 7

Monday, September 10, 2007

Here I am. It’s my last surgical rotation. I am on the Cardiothoracic Service at the VA hospital. The VA hospital is a hospital that is set up for Veterans of the military. I am looking forward to Cardiothoracic, because I am told that the hours are better & the people are nice! Wow! What a fascinating idea, huh?

I don’t have to be in until 6:45. Which means I don’t have to wake up until 5 a.m. It feels positively heavenly to sleep in an extra hour. It takes me a little longer to get ready, because I am going to be on call tonight, so I’m going to be at the VA for about 30 hours. I need to make sure I have enough food and stuff.

I get to the Surgical Intensive Care Unit (SICU) a little bit late, because I have an awful time finding where I’m supposed to park & how to get there. As I walk in, one of my classmates is standing there & says really loud in front of all of the residents and other students, “You’re late.” I say, “I know,” and just keep walking until I find my intern. I am not pleased. It’s bad enough that I’m late, I hate that she just yelled it out for all to hear.

I meet up with my intern & he’s totally cool. We talk a little bit & we start rounds. I meet our attending who is incredibly cool. He’s a Hungarian doctor who has been practicing for quite some time. He knows a ton about Korea & the world in general, and he has some great stories. I’m already happy to be on this service.

I find the VA to be a very different kind of hospital. Things are a little slower. Things are a little sloppier. I go to get scrubs so that I can go into the OR. I find that the VA uses Purple scrubs. That’s right. Purple scrubs. And we’re talking SERIOUSLY purple… as in Grimace or Barney. I feel ridiculous.

Also with Cardiothoracic at the VA, there is usually only 1 operation a day! How great is that! Unfortunately… all of our operations are basically 5-7 hrs long. Ugh. Our first and only surgery today is an Aortic Valve repair with a coronary artery bypass graft (CABG pronounced like “cabbage”). The first part of the operation is when someone has a bad heart valve & so we put in an artificial valve in its place. The second part of the operation involves the blood supply to the heart. The heart is responsible for delivering blood to the rest of the body. But it also needs blood for itself. So it has several small arteries that shoot blood to the different parts of the heart.

When people have a heart attack, what is happening is one of these arteries gets clogged & so that part of the heart does not get the blood that it needs… so that part of the heart stops working, which is why heart attacks are so dangerous. Sometimes we can figure out that one of these heart arteries (coronary arteries) are starting to get clogged and are in danger of being completely clogged off. If it’s just one of these arteries that gets that way, we’ll usually put something in it to keep it open called a stent. If it’s more than one of these coronary arteries, we do a CABG. To do a CABG, you take a long piece of vein from the leg, cut it into pieces & sew it into the heart so that it carries blood around the area of the clot. It’s a really cool operation & it’s done all the time.

The nurses in the OR are really really really nice. I really like everyone there.

The surgery starts off with them getting the vein. It’s pretty cool. But the real excitement comes when they open his chest. It’s amazing. They cut the skin down to where you’re almost at the bone. Then they use a hand-held saw to cut down the middle of the chest plate. They use their hands to pull the 2 sides apart & there it is. The heart & the lungs. Un-freakin-believable.

They let me put my hands in and feel the heart and the aorta. They let me see the messed up valve. They start pimping me on aortic valve disease. I do alright. They pimp me on how to treat a heart attack. I do alright. They connect the heart to a gigantic heart bypass machine. VERY COOL. Then with the heart basically empty, they go put in a new valve, they connect the veins. When they are done, it looks like this crazy Frankenstein heart. It is SO FREAKING COOL. Then they fill the heart back up to do the last bit of reconnecting. When they poke a small hole in the aorta, blood comes squirting out. And no one even so much as flinches.

When they are done sewing everything together, the heart isn’t quite beating in the right rhythm. The patient is having a rhythm problem called ventricular fibrillation (v-fib). It is often described as looking like “a bag of worms.” That is EXACTLY what it looks like. I’ve seen it on tv before. I’m seeing it less than 1 foot away from me right now. They take out the internal paddles and they shock the heart. Things are cool once again.

To close the chest back up, they use these huge wires that are connected to a needle & basically tie the chest back up with the wires. Then they sew in 3 layers of thick stitches followed by a layer of thin stitches. And when they’re done… you just have this small red line going down the center of their chest. You would never guess that just 20 minutes ago, his chest was wide open & you could see his heart & lungs.

By the time I get out of the operation, it’s 4 p.m. and I have yet to eat. This is life on surgery. You never get to eat when you’re supposed to.

And my feet hurt like CRAP. I made a mistake and wore dress socks today. I decide today that I am never wearing dress socks again for the duration of my M3 year. I am only wearing black athletic Under Armour ankle socks. It’s the only thing that keeps my feet from feeling like they are going to explode.

I normally would be able to go home at this point. But I am on call tonight. I find the intern I am on call with & he tells me to just hang out in the student call room until 7.

On my way back to the student call room, I run into some students, & I laugh & say something about how that student had yelled out that I was late. They tell me that before I got there, my intern had actually said I was late. Then that student had told my intern and everyone else that he was getting by far the best medical student in our class. She told everyone that I had all of this clinical experience from before and that I knew everything and that he was going to have the best experience with me. Wow. Funny how mad we get at people when we don’t even really know the whole story, huh?

My intern for the night is kind of interesting. When I talk with him, I get the sense that he’s really scared. And I would be, too. He’s the ONLY “surgeon” in the hospital for every single surgical patient that night. And I say “surgeon” because he’s not really a full-fledged surgeon. He’s been a doctor for exactly 3 months. There are other doctors that he can call to come in… but he has to take care of everyone until then.

Before I got to the VA, everyone told me that I would get to sleep all night on call. But I quickly abandon any idea of sleep, because I figure he’s going to need as much help as he can get. We start off quick. He has a bunch of people that needs blood drawn. So I do it. I haven’t drawn blood in a while, but I’ve probably done about 1000 blood draws in my life… with half of those blood draws on pediatric patients. But after drawing blood from little kids & babies, I am stunned at the size of these people’s veins. I could probably get a garden hose through some of their veins. The intern is amazed that I’m doing so well. But please. If you can get an IV in a 1 month old, you can draw blood from a 50 year old.

After I do some random errands for him, it turns out we have a guy in the ER there who probably is going to need his appendix taken out. So I have to go into the Operating Room with him. I draw blood on him & then I go to make sure everything is set. I am going to be operating with my old chief from Surgical Oncology. I pretty much hate this guys, but for a brief second, I get kind of excited, because I think I might get a shot at doing a lot of stuff.

But it’s not to be. He’s in a pissy mood. And he ends up screwing up a bunch of stuff during the operation. He starts trying to blame me for stuff. He wants me to hold something in place that is halfway across the body. When I do this, my head can’t help but be in his way. He yells at me to move my head. I look at him like, are you kidding? But the attending basically tells him to calm the hell down and leave me alone. I am so glad when we’re done.

After the appendectomy, I find my intern. It’s so obvious he’s scared, because he asks me to go around and just make sure everyone is breathing… literally… he asks me to walk from room to room and just check to see if they are actually breathing. It’s a ridiculous request. But I jump to my feet and go do it anyway. The guy’s scared. This is the best thing I can do for him. When I’m done, it’s 1 a.m. and he thanks me for everything I’ve done and tells me to go sleep.

Sleep is difficult. The bed sags so much in the middle that it’s like sleeping on a hammock. Which would be fine… except I sleep on my stomach, which if I tried to do here, would bend me backward.

When I get up in the morning, I feel pretty much cooked. All I can think about is going home and sleeping.

After rounds, my intern lets me go home around 9. Sleep is good.

Tuesday, September 11, 2007

After I wake up from my nap, I have a great afternoon of running errands.

Then I spend my evening talking with a fellow Christian sister that needed to talk through some stuff. It’s interesting, because I find that a lot of times when I am talking with others who need to talk… I end up offering advice in the way of sharing my own experiences as examples… and as I do so… I find that I end up gaining so much from the experience. In this particular case, it makes me realize again, just how much I have to be thankful for and just how much God has done for me along the way. It also makes me realize how negligent I have been in maintaining my own spiritual walk.

It’s a good day.

Wednesday, September 12, 2007

It’s another CABG! This time, they get the vein out of the leg using some tubes inserted into a small cut they make in the leg.

Once again, I get to see the heart and lungs.

On Monday, one of the nurses had told me about some of his favorite questions. One of those favorite questions involves understanding how 2 drugs (heparin & protamine) work. So on Tuesday night, I had studied heparin & protamine.

My attending asks me about heparin. I nail the question. He doesn’t ask me any other medical questions after that. Instead, we just chat. It’s a great feeling.

I get to go home by 4. Woo Hoo!

Thursday, September 13, 2007

We have Grand Rounds in the morning. It’s pretty boring. You see, every Thursday morning, we have to listen to a series of lectures. They tend to be fairly boring. At the VA, we watch the lectures at MCV via closed circuit TV. They serve breakfast, too! As we sit there, most of the room is empty. The students are all on one side and we are trying to read and study. We whisper to each other some, but it’s a lay low kind of situation. The Chief is there with the interns and residents. They are talking about all of the patients and stuff. One of the students is whispering a little louder than the others. The Chief asks, “What’s his name?” We don’t know who he’s talking about at first. So the Chief says, “He needs to shut up.” Seriously. Is that necessary? I can’t remember the last time anyone who was sober used the expression “shut up” in a serious way. What a freakin’ jerk. I don’t know why this guy is even a doctor.

Afterwards, I go to the OR for a lobectomy. This is where we have a patient who has cancer in the upper part of his right lung. So we are taking that part of his lung out. It’s pretty cool, because instead of opening his chest down the middle, we are opening him up inbetween 2 ribs from the side. As they are doing this, they call me over to their side to hold the lung out of the way so that they can staple off the arteries & veins. It’s pretty amazing. The lung in my hand feels like this gigantic squishy water filled sponge. It blows my mind to think that I am getting the chance to do stuff like this. They also have to remove part of the airway that this part of the lung is connected do. When they are done, they pull the piece of lung out and it’s like, Ta-daahh! I’m staring at this upper lobe of the lung in complete awe. It’s so cool! Then they begin to sew the airway parts back together so that they are reconnected. They let me get a good look inside to see what it looks like before & then let me see halfway through so that I can see the 2 parts of this tube coming together. I really love the surgeons on this surface, because they are so good about trying to show me everything.

I have to leave before they finish, because I have afternoon lectures. But this might be my favorite operation to have watched by far. I think mostly because I really got to see what they were doing and I got to help.

Friday, September 14, 2007

We have no surgeries today. So there is really nothing to do. I help out my intern a little bit. But basically, he sends me home at 1 p.m. I’m grinning from ear to ear.

Saturday, September 15, 2007

I got some bad news last night.

One of the kids I used to work with on the Peds Oncology Floor passed away. His name was Peter Choo. He had been fighting Neuroblastoma (cancer of nerve cells) for over 7 years. He was 13 when he died.

Peter was an amazing kid. Even though he was 13, he looked like he was 7, because of all of the chemotherapy and radiation he had had in his life. But he was smart and wise beyond anything you could ever imagine.

For his Make-A-Wish… Peter asked for a visit with Pope John Paul II. Unbelievable. And after initially saying that they didn’t think it was going to happen they did it.

Peter was an unbelievable food connoisseur. He ate every kind of nasty sushi & sashimi you could imagine. He loved oysters. My running joke with him was that when I first had him as a patient, I told him that when I left work I was going to get him an oyster. And then from that day forward, everytime he saw me, he would ask me where his oyster was & I would come up with a ridiculous story about how I went to get the oyster and something happened. My excuses got more and more preposterous everyday & it made him laugh.

Peter was an amazing chef. I’m not talking like making spaghetti or mac-n-cheese. Peter had me completely enthralled as he told me about how he made a Turducken for Thanksgiving. This is a chicken stuffed in a duck stuffed in a turkey. Most people order Turduckens. Peter made one on his own. Peter & I would talk about our favorite cooking shows. We both agreed that Rachel Ray was a lame cook. We both loved Iron Chef Japan & hated Iron Chef America. We were both HUGE fans of Top Chef & since the hospital didn’t get Bravo TV, I would tell him about each episode.

In the last year or so, Peter fell in love with tropical fish. Again… we’re not talking about goldfish or some tetras. This kid had a full-blown tropical environment. He knew what fishes he needed to put together to ensure an ideal ecosystem. He knew what fishes tended to be more aggressive… which were bad for corals… He had a 20 gallon tank. He showed me YouTube videos of his fish. My favorite fish moment came when he was in the hospital & he had to poop. He was in the middle of showing me and a nurse one of his videos & telling us about his fish. Well, his dad put him on a bedside toilet & the nurse & I were going to give him some privacy. Peter got on the toilet, pulled his laptop over and then started talking about his fish. It was so freakin’ cute watching this kid sitting on the toilet, while talking about his tangs & blue dories.

But my absolute favorite moment with Peter came one early morning. See Peter’s Korean, but I don’t think his family realized that I was Korean, too. They definitely didn’t realize that I SPOKE Korean. So one morning I came in because Peter had accidentally wet his bed, and his Dad wanted me to stay with him while he went and got stuff for the bed. Peter was half asleep, sitting up in bed. And I asked him in Korean, “Did you sleep okay?” Peter, still half asleep, nodded yes. I asked him in Korean, “Did you have any pain?” Peter, again, still half asleep, shook his head no. Then I touched his cheek with my hand and brought his head to my chest for a hug. I don’t know that I have the words to describe how special it is to share a quiet, whispered conversation with a kid in the early morning hours. When the world is quiet, and all you can hear is the hushed sound of each other’s voices. And feeling so much love for this amazing little man just welling in your heart and eyes. But even more special… was being able to share that moment in a language that was spoken to me as a child as well.

I’m going to miss Peter. I miss him already. I am so heartbroken that he had to deal with this awful disease. I am happy that he is no longer suffering. I am happy to know that he is at peace.

Thank you Peter Choo. For allowing me to be your friend.

Sunday, September 16, 2007

I go in for Rounds in the morning. We have a patient in the ICU named Mr. EC that had a CABG done about 4 weeks ago. He never woke up from the surgery. And he’s been having all kinds of medical issues since then. He’s 85 years old and the doctor who’s with us today is talking about discussing with the family whether or not we are going to continue keeping him alive. It’s a pretty sad situation, because I wonder why we even operated on him to begin with. At 85 years old, this is a pretty intense operation. I hope for a good outcome for him… I just don’t know what that outcome would be.

Surgery Week 8

Monday, September 17, 2007

It’s my last week of surgery! I can’t wait for this to be over. I am starting to get physically very worn down. I’m tired of all of the standing I have had to do. My feet and back hurt so much it’s not even funny. I hate that I almost never get to eat lunch. I hate that my body has gotten used to not eating for 10 hours at a time. But it’s almost done!

We start with Rounds. And we go to see Mr. EC. We have a different doctor with us today… and we bring up the discussion that we had on Sunday. How the surgeon on Sunday had talked with the family about removing life support. The surgeon today hears this and wonders why we are having this conversation. He feels that even though he’s pretty sick, he’s not in any actual organ failure. This just has all of the makings of an uncomfortable head on collision.

After rounds, we have… another CABG. How can this be so humdrum to me so soon? Sheesh. Our CABG patient is an interesting man. Mr. JZ was in the hospital, but asked if he could go home for the weekend before his operation. Why did he ask for this? So that he could watch the Virginia Tech game. Sheesh. They were just playing Ohio for crying out loud. He’s an interesting man. He lost his leg in the Vietnam War & he also has a ton of scars on his stomach from the grenade that tore through him. I’m in awe of what this man has been through.

His CABG goes well. And I’m very glad.

After the operation, we go upstairs to the Medical ICU to do a consult on a patient. The patient’s heart had stopped last week & so the team upstairs had started CPR. Well, the patient also has a history of osteporosis, so his bones are fairly brittle & between the different members of the team, they broke a bunch of ribs to the point where he has something called a flail chest. This is where a huge section of ribs has broken off & is not like a little island of broken ribs. The problem is these broken ribs are pointy & they can nick and cut things. This has happened to him and he now has blood in his chest cavity that is squishing his lung and collapsing it. He needs to have a chest tube placed. A chest tube is exactly that. It’s a tube placed in your chest. It is supposed to suck out air or fluid. Whatever it is that’s causing your lung to collapse.

I get excited, because I’m hoping my intern will let me do it! As soon as we get out of the room, he says I should do it. I get really excited! We go to talk to one of the attendings. He wants a CT scan to be done first. My intern & I look at each other, because we know what this means. A CT scan won’t get done for a while. I’m not going to get to do it. Oh well.

So instead, I have to settle for going home at 4:30. Not bad.

Tuesday, September 18, 2007

I go in for Rounds & we have an interesting situation. The 2 surgeons that had kind of disagreed about discontinuing life support on Mr. EC are both in during Rounds. They agree to talk to the family together. When we are done with Rounds, the surgeons go to talk to the family. After much discussion, the surgeons come back. The family has decided that as soon as the rest of the family arrives, they are going to remove life support. The surgeons put in an order for a large amount of morphine to ensure that the patient doesn’t feel any pain and to be given just before they take him off of life support.

It’s pretty intense. I am surprised by how matter of fact this seems to be to everyone. I understand that death happens all of the time. But in this case, we are taking a person off of machines that are keeping him alive… and we are giving him a significant amount of medication that is going to hurry up the process of dying. I’m a bit conflicted. I’m not quite sure what to think about this. On the one hand, he is 85. He has no real chance at a meaningful recovery. Even if he gets through his sepsis, the best possible outcome for him is going to involve continuous nursing home care. But I don’t know how I feel about the fact that we operated on him to begin with. And that we were going to accelerate the death process.

I don’t really get to figure this out, because I have to go into the OR for another CABG. This time, I get to help open the chest up. After the attending is done with the saw, I help pull the chest open & then I help him as he works on the arteries. I am having a blast… but then a second surgeon comes in and I have to step away & let him help. Poop.

But I DO get to some stitches! They have to take the vein out of the leg by opening up his leg from his ankle area all the way up to his groin. So they let me do about 5 inches of sutures. The Physician’s Assistant tries to be a big shot & tries to show me a way to do it that he thinks is great. It’s not a great way to do it. It’s awkward & kind of dumb to be honest with you, because it uses really poor mechanics. He can’t figure out why I’m having so much trouble with it… but when his back is turned, I just start doing them the way I was taught by the Surg Onc surgeons. When he comes back, he goes, “Wow! That’s Great! Where did you learn to do that?” I laugh and I tell him I’ve only done this twice, but I got to watch it done this way on Surg Onc. He leaves me alone. When I’m done, I look up and down the leg. My area of stitches is so obvious, because it is perfectly even & it is not leaking at all. I am very happy with the job I did.

I go back up to the heart & they have me hold the heart for them while they sew the veins to them. The operation has gotten to be same old same old. But holding a human heart is just as exciting as it was the first time I did it. His operation goes well.

When I come out of the operating room, Mr. EC is gone. His bed is gone. The room is empty.

I get sent home at 4.

Wednesday, September 19, 2007

It’s Wednesday. It’s my last day of operating. I am tired from doing 2 CABG’s in a row. The exhaustion of surgery has accumulated & now I feel like a 90 year old man trying to walk on beat up feet. But I’m also giddy, because I know this will be my last day in the OR.

We are doing… drum roll please… another CABG. It goes very smoothly. I don’t end up doing much. And at 12:30, the attending jokes about the fact that all I saw was CABG’s. He asks me if I am going to be in the afternoon surgery. The afternoon surgery is a pacemaker removal. It’s supposed to be a 30 minute operation. But my intern had already told me I could leave after the CABG. So I tell him that I won’t be in it. So he tells me to then go at least talk to the patient before I leave, because he has an interesting story.

I go to speak to Mr. IG. Mr. IG is 24 years old and originally from Puerto Rico. When he was 22, he started getting really short of breath all of the time and he was always tired. When he went to the hospital in Puerto Rico, they discovered he had Idiopathic Dilated Cardiomyopathy. This is a disease where your heart chambers start getting really big & the heart muscles just aren’t working very well anymore. So you’re not getting the blood that you need anywhere. The thing is it’s idiopathic, which means that no one knows why it happens. They brought him to MCV where they put him on an artificial heart. He had the artificial heart for about 5 months, before he got a heart transplant. We talked about what it was like to have the artificial heart. And we talked about how cool it was to have had 3 hearts. He had his own diseased heart, he had an artificial heart, and now he has a great brand new heart. It’s a cool story. I love hearing it.

And then… I go home… at 1 p.m. It feels freakin’ great. But the downside… is that I have to study for my Surgery Shelf Exam, which is the written exam for all 2 months of surgery. It’s a National Exam, so it’s not necessarily based on what I got to see here. I also have my Oral Exam in the afternoon.

I try to study… but it’s hard. I’m tired. And I just want to sleep.

Thursday, September 20, 2007

My written exam is brutal. I’m laughing because it’s so hard. But it’s done.

My oral exam… I crush. They are supposed to ask 4 questions. They only ask 3 because I clearly know my stuff.

And that’s it. I am done.

I can’t believe it’s been 2 months. I can’t believe I’m done with surgery. It was a hard 2 months. I saw a lot of cool stuff. I learned a lot. I feel smarter than I have ever felt in my life. I know that if I got through surgery, I can get through anything.

I am so thankful for God carrying me through, because I know beyond a shadow of a doubt that there is no way that I got through this on my own.

I’ve seen a lot of good things. I’ve seen a lot of bad things. But most importantly… I am getting a better and better sense of the kind of doctor I want to be.

Surgery Week 5 & 6

Surgery Week 5

Monday, August 27, 2007

Today, is my first day on my new surgical service, the Transplant team. Everyone who heard that I was doing Transplant surgery asked me, “WHY???? What did you do to get stuck with that???” Apparently, Transplant surgery has a reputation for being extremely tough. But I’m lucky, today. There is NOTHING going on. For the most part, all I do is sit in the team room and try to read, while meeting everyone.

One thing I did get to do was go on a consult on a lady with an infected AV graft. You see, patients who have constant kidney problems have to go on dialysis. Dialysis involves taking your blood, filtering it, and giving it back to you. This is what your kidneys do all the time.

So in order to make this work easier, a lot of times, they will do a surgical procedure where they connect an artery in your arm with a vein in your arm. This is called an AV Fistula. If you have to use some artificial tubing to connect them, it’s called an AV Graft.

We were called to check this lady’s graft to see if this lady’s graft needed to come out, because she was showing signs of endocarditis (infection of the heart… usually the valves).

Afterwards, I met one of our attendings and our Chief talked about the case with the lady. She is a bad surgical risk, and it looks like a dangerous thing to do. All of a sudden, the attending looked at me and pimped me by asking what are the causes of endocarditis… I was COMPLETELY shocked, because I was under the impression that attendings didn’t really talk to students on this service. But I blurted out, “IV Drug Use, Rheumatic Fever, and Lupus.” Ding Ding Ding! He said, correct… and then also told me about some unusual causes like colon cancer for some reason…

At 5:30, my chief told me to go home. He told me that it was okay to wear scrubs all day on days that we’re not in clinic and that I had 3 kidney transplant procedures the next day!

It was… a great day!

Tuesday, August 28, 2007

Rounds are SO much easier and efficient on Transplant. It’s amazing how well everything works.

Overnight, we had a patient who got a kidney and pancreas transplant. The donor was a young teenage girl who was riding on the back of a truck and the truck hit a bump and she got thrown off the back and hit her head. Lesson learned… don’t ride on the back of a truck.

The other kidney is going to a Ms. LM this afternoon.

But before that transplant, we are taking the kidney from a middle aged son, Mr. EC Jr and transplanting it in his dad, Mr. EC Sr.

I watch the kidney removal, watch the kidney get prepped to be implanted, and then go to watch the kidney get put in.

It’s a really really long process. The attending for the 2^nd case is the head of transplant surgery. He’s pretty intense and scary. He asks me a whole bunch of questions about myself… including whether I was religious… and what religion I was… I obviously answered these questions honestly and openly, but I couldn’t help but wonder… where the heck is this going? Very weird. He asked me a lot of questions about my life story and how I came to med school and what I was interested in doing. I think he thought I had a pretty interesting life story.

It was hard to see a lot for both of these operations… but it was really exciting cool to see the kidney get implanted and go from being whitish gray… to a pretty pink. And then getting to feel the blood as it flows through the artery was really amazing.

Right after that, I scrubbed in to see Ms. LM get her kidney. This time, it was brought in on a special machine that kept preservative and blood flow running through it. It was pretty amazing. I got to watch it taken out of the machine, and prepped. And then… when they had opened up the space in Ms. LM and they were ready for the kidney… I finally got my moment…

Perhaps, I should explain… when I used to work in the ER, I was working a night shift… and around 4 a.m., they called me to the front and asked me to transport a lady in a wheelchair to a room upstairs. As I took her admission packet, I looked down and saw that she was here to get a heart and lung transplant. So I started talking to her about it. And when I dropped her off… I remembered feeling so privileged to be the person that got to take this woman up to get a new lease on life. And as I left the room, I shook her hand and said, “Good luck with your transplant today, ma’am… and congratulations.”

I walked back down that morning feeling so incredibly happy about my job and being so thankful to God for giving me a chance to walk with people in this way.

So back to Transplant surgery… when I assigned myself to Transplant surgery… I was a little reluctant, because it was known for being kind of tough… but the one thing that convinced me to take the hit… was the prospect of possibly being able to deliver the organs for someone getting a transplant… whether it be taking a cooler to the helicopter people… or bringing in a cooler to the OR.

But in the OR, now… I looked up as my attending said to me, “Dr. Lee… would you like to bring us the kidney?”

I said, yes, sir… and walked over to the table and picked up the basin filled with ice and saline solution and the kidney… and carried it over. The Scrub Nurse laughed and said, “Don’t drop it.” Right. Like that thought wasn’t SCREAMING through my head about a million times. And I felt this rush of joy and happiness run through my body as I brought the Kidney to the table… and getting the opportunity to play a small role in giving Ms. LM a brand new quality of life. Everything else after that was a bit of a blur. I got to see the kidney pink up. I got to feel the blood flowing through the vessels. I got to see urine coming through the tubes.

All of that was great. But the most important thing… is that I was able to have the one moment that I was hoping for more than anything.

All in all… I spent 10 hours straight in the OR… with just a chewy granola bar for lunch… My back, feet, calves, and shoulders were KILLING me… I struggled at times JUST to stay awake… they sent me home as soon as the surgeries were done…

Wednesday, August 29, 2007

After 10 straight hours of surgery, I wake up this morning feeling like someone beat me with a baseball bat. Walking in to the hospital, all I can think about is when I get to sit down.

Rounds are a little painful just because I’m so tired… but it’s really satisfying to see that all 3 of our kidney patients are doing well.

After rounds, we have some down time. I am very grateful for it.

Later in the morning, we get a call for a surgical consult on a former transplant patient with a large abscess on the back of his neck. I go to the clinic with the fellow… it’s pretty gross… and the patient has less than desirable personal hygiene…

It looks like he is going to get taken into the OR to get it drained.

That afternoon, we go to clinic. I don’t actually get to do anything… but we see some interesting stuff. One of our patients got an AV Fistula done a while ago and I get to feel and hear it. It’s amazing what these things feel and sound like! Listening to it is like hearing a whirring and whooshing of an ultrasound machine. It’s amazing.

It’s a fairly uneventful day. And quite frankly… I really needed it.

Thursday, August 30, 2007

Thursday mornings, we have Grand Rounds. Grand Rounds is a lecture with all of the residents, interns, and students. It’s usually on a topic that has very little to do with the students. Today’s session is on the hospital’s disaster plan. On our way in, I run in to my old Chief. He’s sitting down and he looks at me and he says out loud to no one in particular, “I miss Kevin.” I laugh and say, sorry. I’m thinking, ha ha ha ha ha!

One of the residents that I was on call with sees me and says, “Hey, are you on call this weekend with me?” When I tell her no, she gets disappointed. It’s cool to know that as a medical student, I am becoming someone that others want to work with. As lost as I feel most of the time, it’s good to know that I am not coming across too terribly confused.

When we get back to the floor, I see Mr. EC Jr walking down the hallway very gingerly. He was the one who donated his kidney to his Dad. He was trying to find his way to his Dad’s room and didn’t know where he was. So I lead him there. And when he walks in, his Dad looks up. And EC Jr says, “Hey pop.” Sr says “Hey. You hurtin’ much son?” And Jr says, “Naah.” And he sits down and the two of them just tap each other’s shoulders. And sit quietly. It’s a simple scene… one that you’d probably see a million times… except for the fact that one son gave his Dad an incredible gift that would dramatically change his Dad’s quality of life. How incredibly cool.

That afternoon, we have D&C (Deaths & Complications). We talk about Mr. WW. It sucks. They talk about this man’s passing and the complications that led to it. It’s so… I don’t know… I don’t have the words to adequately describe it. All I kept thinking was that… this discussion just did not do this man justice.

Friday, August 31, 2007

Today is a pretty busy OR day. My first case is a parathyroidectomy. This is a pretty complicated procedure. And I’m in with a pretty intense doctor. I get asked some questions by my chief before I go in… and I do well. I get asked some questions by the attending… I miss the first one… but then I recover and do pretty well… The operation is pretty tricky. And some stuff goes very badly. And this attending throws these really intense, stressful temper tantrums every time he doesn’t get exactly what he wants. He has me holding retractors for him, and he gets mad at one point and positions my hand a certain way and says, “THIS is how you hold this.” About 5 minutes later, he gets upset because he can’t find what he’s looking for. He looks at my hands and says, “Why are you holding it like that? Hold it like THIS.” Keep in mind… I haven’t MOVED since he positioned me. About 10 minutes later, he gets frustrated and yells at some other folks… then looks at my hands and says, “I told you to hold it like THIS.” Again… I haven’t moved since he positioned me. What a delightful man.

At various times during this operation, I contemplate WHY I am even doing this. I have elaborate fantasies of me just dropping the retractors and walking out of the OR. I picture myself walking down the hill, getting in my car, and driving home to Fairfax. I imagine other things I can be doing for a living… ALL of them involving waking up at 9 or 10 a.m.

Of course… after thinking about all of this… I also remember all of the ways that God brought me to Medical School. And I laugh. He got me through everything up until now… he’ll get me through this.

After 5 hours of this painful cycle of him yelling and throwing temper tantrums, I am exhausted… and all I want to do is drink a gallon of water and eat a gigantic bowl of food. I don’t care what kind… any kind.

I have just enough time to inhale 2 chewy granola bars and then I have to go back into the OR… with the same Doctor. It’s another painful case. The patient is getting a graft removed from her arm. She is at high risk for anesthesia, so instead of putting her to sleep, they do a nerve block on her so that she will not feel any pain. She is also NOT supposed to be able to move her arm… but the docs that did the nerve block didn’t do a good enough job… and even though she can’t feel her arm, she is still moving it. This causes a LOT of stress during the operation. And the disturbing thing is that the Attending is in such a foul mood that he’s YELLING at her to stop moving. It’s really nasty and stressful in there. He’s yelling at an 86 year old woman. I understand how stressful it is for her to be moving her arm… but it’s so unnecessary to be this way.

After 2 hours of this crap, we’re finally done. When I get upstairs, I find out that one of our patients, Mr. DD, who was admitted that morning is looking like he has a serious problem with his liver transplant. He had gotten his transplant 3 weeks ago. And now part of the transplant is leaking in a very bad way. He gets rushed to the OR. In the OR, they discover that one of his arteries is completely blocked. So it caused part of his liver to die off. It’s really stressful in there, because nothing is going right. There are 2 attendings and a fellow that are scrubbed in. I’m over by the wall watching. There is a lot of yelling. I decide it might be best to leave.

Upstairs, we sit in the war room and we talk about the mess of the situation. About an hour passes and the attendings come in. He needs a new liver. The thing is… we actually had a liver that was supposed to go to another patient later that day. So now what do we do? Do we give the new liver to Mr. DD? Or do we give the liver to the person who was supposed to get it? The thing is… it’s not entirely up to us… because there are rules that control these situations. Our attendings put in a formal request to find a way to give the new liver to Mr. DD.

I leave that night not knowing what’s going to happen.

It’s labor day weekend… and I actually have 3 days off. I am going home to NoVa to get some serious sleep and some good food.

My first week of transplant was a weird ride. There was a lot of cool stuff… but some moments when I was absolutely miserable.

Saturday, September 1, 2007

I drove up to NoVa in the morning.

It’s funny how much you get used to living a ridiculous life. Being at home, I couldn’t get over how weird it was being back to a normal life. I didn’t realize how tired I was. I didn’t realize how drained I was. I didn’t realize how much I didn’t want to go back.

It’s good to be home.

Sunday, September 2, 2007

I sleep like a rock and then wake up to go to church. It’s great to see everyone. When I was teaching Sunday School, I would walk through the church in the mornings and get hugged by about a thousand kids ranging from 4 to 20. I miss that. I see one of my favorite girls who jumps up into my arms and kisses me on the cheek. She says she's not letting go until I die. I think everyone needs to hear that from time time.

I also get to spend time with one of the high school kids that I didn’t get to see all summer. We sat down and had time to talk. I realized as I was talking to her that this is where God needed me to be… and she needed to hear what I had to say.

I spend the evening starting to feel relaxed… I spend the evening just talking with my Mom. I don’t want to go back. But I know I can get through the rest of surgery. I just have 4 more days of Transplant Surgery… and then I have Cardiothoracic at the Veterans Hospital. Cardiothoracic is supposed to be very laid back.

So I know that if I can just get through 4 days of Transplant Surgery, I’ll be okay. I’m driving back to Richmond on Monday morning to finish this out.

I think I’m ready.

Surgery Week 6

Tuesday, September 4, 2007

I go back to the hospital feeling well-rested!

I find out that the liver went to Mr. DD and the original person was sent home. I’m told everything went well. And he actually looks great. I still can’t get used to how a patient can be so sick, have their insides opened up… and then later on… look perfectly okay. It’s so weird.

One of our patients who got a Kidney and Pancreas Transplant, Mr. LS is doing so well. He’s mentally not all together. This happens when people get sick. He was so out of it that his nurse walked and found him trying to drink from his own surgical drain. Oh God.

Today is a semi-busy OR day. We have a Kidney Harvest and Transplant today. This particular situation is interesting. This is a “Variance” Donation. “Variance Donation” works like this. Suppose someone wants to donate a kidney to a relative. But they are not a good match. Well that person can instead, donate to the Transplant List anonymously. If they do this, then their relative goes to the top of the list for the next available matching kidney.

Our lady today is doing this… not for a relative… but for a friend… that she met on the internet… Hmmm… a little weird…

She also wants pictures taken of as much stuff as possible… She says she wants to use the pictures to encourage people to donate their kidneys. I wonder if they did a proper Psych evaluation on her…

I watch both the harvest and then the transplant. The attending for the transplant is the scary one. But he actually isn’t too bad today.

Afterwards, I go to watch them put together an AV Fistula. It’s so cool to see them sewing a gigantic vein to an artery.

At the end of the day, I have been on my feet in the OR for 10 hours again. I am so freakin’ tired. Once again, all I get for lunch is 5 minutes with some nutri-grain bars. It’s funny because you get hungry and lightheaded for about an hour… and then after that you’re just too hungry to be hungry.

Still… seeing a kidney turn pink after it’s been implanted? UNBELIEVABLY cool.

Wednesday, September 5, 2007

I am starting to find my groove. I am getting faster at getting stuff done. I’m getting better at being helpful. It’s a great feeling to no longer just feel like extra baggage.

It’s not a SUPER busy day in the OR, but there’s enough to keep me busy.

One of our patients is an 8 month old baby who got a liver transplant at 2 months old. He actually got part of his Mother’s liver. His name is THM. He was born with a disease that causes his blood and liver to hold on to too much iron. It’s usually fatal in babies. He had been doing okay after his transplant, but now he keeps having this weird cycle of developing fevers and watching his Red Blood Cell Count drop. They can’t seem to figure out what’s going on with him, so today, we are doing 3 things. We are putting in a Central Line because they have been having a TOUGH time starting IV’s on him. We’re then doing a liver biopsy and a bone marrow biopsy.

He’s such a cute baby and I feel so bad for him as he lies there unaware of what’s going to happen to him. When they knock him out so that they can intubate him, it is really disturbing to see his limbs just go completely flaccid. Intubation is when they a patient gets a tube put down their throat and just above their lungs so that they can be kept breathing while at the same time knocked completely out. I’ve never seen a kid go from being awake to being intubated before. It’s a little hard to get used to.

The Central Line gets put in. The liver biopsy goes well. It’s time for his bone marrow biopsy. I have sent off many kids to GET a bone marrow biopsy done. I never knew that THIS is how it gets done. It is incredibly BRUTAL to look at. A gigantic needle that looks more like a pointed stake is pushed with a TON of force into the patients hip bone area. Then they use this handle on top to just screw the needle deeper and deeper until they get a good section of bone marrow. It looks UNBELIEVABLY painful.

While we are in the OR, I find out that we have a kidney transplant scheduled for that afternoon. It’s for a nice grandmother named Ms. MH. When I meet her, she spends some time telling me how excited she is to get this kidney. It turns out that because her kidney has been giving her difficulty, she has been on fluid restriction. This means she can only drink so much liquid a day. She tells me the one thing she is looking forward to the most is that she will be able to drink as much as she wants. I am really happy that she is getting a kidney.

Her operation takes 5 hours. I can’t believe how painful it is to just stand. The operation goes well though.

I limp home at the end of the day. I can’t wait to sleep.

Thursday, September 6, 2007

A really uneventful day.

A lot of classes.

Blah.

I think I get MORE tired when I’m not doing anything.

Friday, September 7, 2007

I’m a little excited about today. First off… it’s my last day of Transplant Surgery! Woo Hoo! Second off… I’m going to get to see my first laparascopic operation! That’s when they stick these cameras into the belly and use special instruments to do what needs to get done. It’s cool because it makes it easier for the person to recover.

I am going to see a person’s gall bladder get taken out, followed by a liver biopsy (sampling of the tissue for testing), and an RFA. An RFA is where a special probe is inserted into an area and high frequency radio waves are transmitted in order to kill cancer cells.

My Chief pimps me before we start, but I nail the questions without any problem. The surgery itself is pretty cool. And it’s with one of the nicer attendings. When the surgery is done, the attending leaves and it’s just me and my Chief. There are about 5 incisions to suture up. My Chief lets me suture up 2 of them. They look great. I know it. He knows it. He’s impressed. It feels GREAT to be able to do some stuff.

The next surgery is an AV Graft. My Chief and I start off without the attending. He lets me Bovie, which is the electrical scalpel. It’s so freakin’ cool. And unlike LAST time, my lenses aren’t fogged up and I can see without any problem. It feels great to finally get to do some stuff.

There were 2 kidney transplants that were done overnight. The kidneys came from a person who had Hepatitis C and they are going to 2 patients with Hepatitis C. One of the recipients also has HIV. Here’s the problem though. Neither of them is producing any urine. This is a HUGE problem.

On top of that, 1 patient is having trouble getting rid of their Potassium, which is potentially damaging to the heart.

The other patient is getting dialysis since she is unable to urinate. During dialysis she develops terrible pain and numbness in her right hand. She doesn’t have a pulse in her right hand and when we get an ultrasound, we see that 1 of the 2 main arteries that supply the hand is completely blocked. The other one is almost completely blocked. Normally we would give her blood thinners. But the problem is… she JUST got a kidney transplant. She can’t get blood thinners. No one seems to know what we’re going to do. As it gets to the end of the day, I am feeling very glad that this is my last day of transplant. I get the feeling that things are going to get bad.

When they decide to send me home, they tell me that I did a good job on the service. It feels great to get the compliment… but even better just to know that I’m done… and I survived.

Transplant Surgery wasn’t necessarily as bad as Surg Onc. There was one attending that was incredibly intense. But everyone else was really nice and fun to work with. The surgeries were REALLY long. I’ve learned that I can go a long time without peeing, drinking, or eating. I’ve learned that it just might be possible for a person to sleep standing up. I’ve learned that the simple act of standing is BRUTAL on your feet and back.

All of this is going through my head as I head home… and I realize that I was a little anxious when I was in NoVa for Labor Day weekend. I was afraid that I was going to be in more uncomfortable situations with my attendings. I was afraid of how I was going to handle the long surgeries. But everything went well this week. That’s when it hit me… getting through this week as well as I did... wasn't an accident... someone was praying for me this week. And I knew who it was.

I called home and I thanked my Mom. She asked me how I knew. I told her I just did. I thank her and my Dad. And I tell them that I love them.

It was a good week.

Sunday, September 9, 2007

I’m on call today. When I get there, I find out that one of my friends who was on at night is still down there in the middle of a call. I go to relieve her and find out that she wants to hang out and suture the patient up, because she’s never had the chance to do so. As she gets ready, she suddenly realizes… she doesn’t know what she’s doing. And the residents are busy doing some other stuff. So I decide to talk her through it. And it’s so cool, because I realize how much I’ve learned. Both she and the residents comment on how good a teacher I am. It’s a cool moment.

We get a call that comes in later that day. It’s a guy who was in a car accident and was unconscious and not breathing and didn’t have a heartbeat. One of the other guys on call decides to take it. So I stand back and watch. There’s a nursing student there as well. When the guy is brought in, they are doing CPR on him. I stand back and watch with the nursing student and this nurse that comes in from another floor. I explain to her everything they are doing and why. They ask me a bunch of questions and I sit there and explain why we don’t do certain things, what kinds of injuries you worry about in these situations. It’s really cool. I can’t believe how much I know at this point. Then the nurse looks down at my ID and says… “wait a minute… you’re just a student!” And I say, yes, ma’am. And she asks me how I know all of this… and I tell her I just do… and that I used to work in an ER before. She asks me if I’m going into Emergency Medicine… I tell her I’m not… and she can’t believe it.

The guy didn’t make it. But in a situation like this… they almost never do. When a person is in a trauma and their heart and lungs stop without any obvious injuries on the surface… it’s never good. When they used the handheld ultrasound on him, he basically had a ton of blood just filling his chest cavity and abdomen. He never had a chance.

That’s the only call of the day really. So we spend the rest of the day just studying. It’s a great and relaxing way to transition out of Transplant. I can’t believe it’s been 6 weeks since I started! Where does the time go?

My next rotation is Cardiothoracic at the VA. I’ve heard this is a cool rotation. And that the people are really laid back. I’m really looking forward to a laid back rotation.