Surgery: Fixing Disease

after 30 hours by ~shiroi-kishi on deviantART

The one central question that surgeons ask: is this surgical or not? That is to say, "Can I do something about this or not?" That one question is paramount because surgeons work in the here and now and their work is very tangible. As one of my interns on medicine said, "You will never feel as macho and more like a man than on surgery." He was right.

Surgery is a realm very much separate from medicine . . . a dark dark realm. I say this because often you will wake up in the dark, go to the hospital in the dark, and possibly leave the hospital in the dark (particularly in the winter months). Only the glaringly bright OR lights punctuate that darkness away from natural light. There are a few critical tenets of surgery:

The List: a list of patients under the care of a surgical team that must be updated at the beginning of the day and the end of the day. This duty often falls to the med students.

Vitals: surgeons are obsessed with patients' vitals over the last 12-24 hours - temperature, blood pressure, heart rate, respiratory rate. These things tell the surgeon the general condition a patient is in, they don't necessarily care how well a patient is doing so long as he/she is not in a critical condition that warrants immediate attention.

In's and Out's: also known as I/O's. Surgeons also obsess with just how much a patient is taking in and excreting out. "In's" include things such as food (whether it's clears, liquids, semi-solids, solids, etc), IV fluids and nutrition, etc. "Out's" are usually urine and stools, but also include drain output, ostomy output, etc.

Pain Control: surgeons are well aware of the damage and pain they inflict upon patients. Thus they always ask about pain control and how to better optimize it. Also, the better a patient's pain is under control, the quicker the patient can usually be discharged from the hospital.

Surgeons do with the ideal of fixing disease; this may be either definitive or not. Gallstones or any one of cholestatic diseases? Remove the gallbladder. Hernia? Choose the kind of repair you'd like, though different repairs have different recurrence rates. Non-healing ulcer on the foot or infection penetrating down to the bone (osteomyelitis) or necrotic foot? Amputate it. Colon cancer? Resect it, though it may come back elsewhere. Regardless, there is either action or no action, nothing in between. In this respect some surgeons have earned that well-known stereotype of surgeons pronouncing themselves God-like, because they have the power with their hands to do something. Indeed, some surgeons scoff at medicine because medical management fails whereas surgery produces direct, definitive, and immediate results (whether those results are good or bad depend on many things).

I've had a very love-hate relationship with my 2 months on surgery.

Love:
- Doing something tangible. As a med student that's kind of limited, but what little I was allowed to do I enjoyed. I liked dressing wounds, I liked stapling wounds closed at the end of an operation, I liked practicing suturing, I liked removing lines and drains and staples.
- Scrubbing in. I love the act of scrubbing in - that OCD ritual of scrubbing your fingers, hands, and arms with soap while being careful not to bump into anything, then gowning up and putting on gloves. It's almost sacred.
- Driving the camera. For a laparoscopic procedure, it's usually the med student's job to hold the camera such that the surgeon and/or resident can see the field of operation. It's not always an easy job because you have to anticipate where the surgeon/resident will want to see next and have the camera centered there ASAP. So one can't zone out as usual, which I'm okay with.
- Thankful patients. More so than on medicine, surgical patients are very thankful for the care you give them (once their pain is under any semblance of control), particularly if you show that you care.

Hate:
- The hours. I cannot stand waking up in the dark, going to the hospital in the dark, and occasionally leaving in the dark. Also, being on call for up to 28 hours straight is rather rough (though the residents are usually nice and let you have at least 5 hours of sleep). I was perpetually tired and grumpy on surgery. I refrained from coffee on days that I knew I would be going into the OR, because caffeine tends to make me pee within 1-2 hours of ingestion. That was tough.
- The OR. While I love scrubbing in to the OR, I disliked the hours in the OR itself. I felt trapped like a prisoner. There are many things I couldn't do, for fear of breaking the sterile field. I couldn't scratch my face, or adjust my glasses, or let my arms fall below the level of the table; I couldn't accidentally brush up against someone's back (sometimes easier said than done in a cramped OR). I also couldn't sit. I'm okay standing for 1-3 hours or so, but after that I begin to stare longingly at the clock. My lower back never hurt as much before or afterwards as it did on my surgery rotation.
- Retracting. While I like doing things, I hate retracting. Retracting is basically where you use an instrument to hold open the surgical field for however long as asked. This could be holding open the abdomen, the intestines, the leg, and yes the anus. At least my arms probably got more toned as a result . . .
- The people. Most residents and surgeons are actually really great people to get along with. But every now and then you encounter one of those stereotypical surgeon-type people that just ruin your world.

Surgery is for those who like action, who like the immediacy of results, and don't have an aversion to blood or really messing with people's bodies. As a friend who wants to go into surgery once said, "In what other field can you cut people open, do horribly painful things to their bodies, and then close them back up without getting sued and thrown in jail? In fact, people pay you to do just that! Because you're a surgeon and are fixing them." For them, few things break the sometimes Zen-like concentration of operating.

In retrospect I almost enjoyed the hours between dawn and dusk on surgery. But I will forever be reminded by the days of staring at the rising sun from a patient's room during rounds, or saying hi every morning to the constellation Orion. And yet, I shall regard surgery as a privilege - for another human being to trust you so completely that they allow you to cut them open and do what you will, all for the sake of improving, even fixing, them. I have nothing but respect for surgeons but it's a lifestyle that I will not miss.

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Medicine: Managing Disease

medicine by ~bloodred on deviantART

Internal medicine, in my experience thus far, focuses on acute management of chronic diseases. This makes sense given the nature of inpatient hospital medicine - you're there to manage the patient acutely and get them better to the point where they can safely walk out the door and not keel over.

Almost every patient I saw while on inpatient medicine was admitted because, for whatever reason, their chronic diseases got the better of them and they suddenly get ill. An alcoholic patient came in with delirium tremens due to alcohol withdrawal. An alcoholic patient comes in with alcohol-induced pancreatitis. A patient with congested heart failure comes in with acute shortness of breath and chest pain. A diabetic patient comes in with a non-healing foot ulcer/injury. A patient in chronic renal failure comes in with shortness of breath. As you see, the majority of our medicine patients have long-term chronic diseases such as alcoholism, diabetes, congested heart failure, or chronic renal failure.

For one reason or another, their disease gets out of control and they experience symptoms that prompt them to seek immediate care. Much of the time it's because these patients don't keep their chronic diseases well-managed and under control, thus they let their health slide. The reasons behind why patients do this is complex and something I can't even begin to explain, so suffice it to say that many patients let their health slide to the point where they need to be admitted to the hospital. They sometimes come to us and almost literally say, "Save me."

We do our best to manage their underlying chronic disease as that usually does the trick in making them feel better. But do we "fix" anything? Not usually. Alcoholics continue to drink alcohol. Diabetics still have diabetes. Congested heart failure can't be fixed. Chronic renal failure is irreversible. The question now is: will these patients be able to take better care of themselves so they don't get re-admitted (at least, not for a while)? From what I've seen the answer is all too often a "no."

This creates an endless loop. Some patients have been pegged as "frequent flyers" because of how often they're re-admitted for the same problems over and over again. I've heard an entire department snicker upon hearing one particular patient's name because the patient kept getting re-admitted for the exact same issue. And every time they manage the patient's chronic disease, symptoms resolve, they reiterate to the patient how to manage the chronic disease, and send the patient out the door. Weeks to months later this is all repeated. I've sensed either a distinct jadedness or detachment from some of the attending physicians.

The longer I spent in internal medicine, the more of that jadedness I felt in myself. I began to feel almost a sense of futility in caring for some of these patients. Many of them I know are unable to adequately make the necessary changes to better manage their health, indeed it can be very difficult for any of us to do! A patient about my age but weighing almost 3 times as much got stuck in a CT scanner. How does that even happen?! Why do I even bother?

Even so, I've had some wonderful patients on medicine. These are people you work your butt off to help get better. These are the people you say goodbye and hope to never see them again, and in all likelihood you won't (not for a long time at least). Every few days there's always that one person to make it all worth it.

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Farewell to the Big Three

Three Fates by ~vivalastan on deviantART

Yet again it's been forever and a day since I last blogged here! o_O Holidays have come and went: Halloween, Thanksgiving, and Christmas. Before I could take notice, even the seasons have come and gone: summer, autumn, and now into winter.

Where was I during all this? Mired in "the big 3" rotations: - 2 months each of internal medicine, surgery, and pediatrics. Because this has practically dominated my life since the beginning of M3 year, it's only fitting that I spend some time elaborating on some of my thoughts regarding these 3 rotations. Here I'll only give a brief intro to each, with the next several posts going into some more detail.
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Medicine (July, August)
I first began describing internal medicine in this post several months ago. Again, internal medicine (usually just referred to as "medicine") is the prototypical idea that people have of what a doctor is - someone with a lot of medical knowledge who listens to you, physically examines you, then orders a bunch of tests and prescribes medications with the hope of figuring out what's wrong and getting you better.

My 2 months of medicine were exclusively inpatient; that is, spent entirely in the hospital on wards. My first month was on the hospitalist service at one hospital, then I was on a ward team at another hospital for my second month. The ward team structure is very hierarchical consisting of 2 M3 med students, 1 M4 med student, 2 interns, 1 senior resident, and 1 attending physician. The med students must "pre-round" before the rest of the team on their patients and then present their patients to the team during rounds. Rounds is basically when the entire ward team goes from patient room to patient room and discusses the action plan for each patient that day.

Surgery (September, October)
In contrast, surgery was an entirely different beast. Whereas on medicine the day began with rounds around 8am to 9am or so, surgery rounds frequently began before 6am and occasionally as early as 5am. The hours were grueling as the days rarely end before 5pm and too often later. While surgery also contains a similar ward team structure, each patient encounter goes much quicker because the first surgeries of the day typically begin around 8am.

Surgery was truly a love-hate relationship. I hated the hours with a fiery passion. I hated some of the people I worked with. And I hated standing for hours on end in the OR (operating room) - my lower back never hurt more than it did on surgery. But I loved doing something tangible with my hands - dressing wounds, removing drains, removing staples, removing sutures, removing lines, suturing, etc. I loved the act of scrubbing into the OR; not sure why, but there's something ritualistic and almost sacred about it.

Pediatrics (November, December)
Pediatrics (more affectionately called "peds") was a world apart from either medicine or surgery. In essence, it's the children's counterpart of medicine. At its core only the patient population differs, but that singular difference is more profound than one would think at first glance. With children come parents and families. And it's a rare occasion to find a child without an adult nearby. So when you address the patient, you're also addressing his/her guardian - if not the entire family. It requires a particular kind of skill to not only deal with kids, but also keep parents in the loop.

The benefit of the peds rotation is that one month is inpatient (with all the trappings of ward team structure) and one month is outpatient in a community clinic. The contrast between inpatient and outpatient is quite literally like night and day, and that deserves a post in and of itself.
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P.S. And why have I chosen a picture of the Fates to represent the big 3? Because, like the Fates attending to the loom of life and death, these 3 major branches of medicine are also intertwined and have to rely on the expertise of the others. It's an intricate balance and each one deserves respect (which incidentally can be a topic and post in and of itself as well, lol).

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Wedding Close to Home

About 3 weeks ago, I flew back home for a weekend for a good friend's wedding. This makes the 4th wedding in 2 years (5th wedding since starting this blog), but it's just as special as all the rest. My friend, Taylor, had been my next-door neighbor for almost 10 years growing up. Even after I moved to a different part of town we remained friends. This wedding was not one for me to miss.

There were many familiar faces that I saw at his wedding, many of whom I hadn't seen since high school. The nostalgia was palpable as I saw people moving on with their lives yet a part of them still unchanged since high school.

The wedding was held in Farmington Hills, MI, at a lovely Methodist church. It was a fairly short wedding between Taylor and Jana. The groomsmen all people I know, two of whom were Taylor's brothers, Jared and Pierce.

I love stained glass windows!

Ring-bearers! They were quite adorable (and hobbit-like, lol).

Lovely flower girl.

The bride and groom (Jana & Taylor), standing with them the groomsmen (Jared, Steve, Pierce, Matt) and Taylor's parents.

Exchanging rings and vows.

Newlyweds!

Best man, Jared. My camera doesn't do justice to how stained glass light falls upon people.

After the wedding, I caught up with some people I hadn't seen since high school before we all headed over to the reception in Bloomfield Hills, MI. The reception hall was somewhat oddly laid out in a long rectangular area. Most of the people at the reception were, I assume, family and extended family members. Those of us who were friends with the newlyweds sat at a table as far back away from the head table as could be. We weren't exactly pleased, but we understood and had fun anyway.

Table 16/20. The young to mid-20s table, lol.

This was how far back we were!

Hmm, maybe this is why we were put in the back . . .

The newlyweds, Jana and Taylor! :-)

There was no wedding cake, oddly. But instead, there was an array of yummy dessert options like this hazelnut creme brulee here.

Blueberry bread pudding and a new drink the waitress named "Table 20" in honor of us sitting in the back (and right next to the bar), haha.

Me and Taylor.

Taylor and Jim.

Me and Jared.

Dancing to "Shout!"

All in all, it was a great night. I had a lot of fun catching up and just laughing. It was great being around completely non-medical people. I wish I could've had more time to chat with Taylor and Jared, but that's alright. I must've had 5-6 alcoholic drinks that night . . . and then had to drive home. o_O Thankfully I stopped drinking fairly early in the evening so I could sober up a bit first, haha.

Backlog: 09-24-11

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Best Friend's Wedding

Wow it's been a while since I posted!! Then again, I say that almost every time, haha.

I can remember almost as clearly as last week, that first day of undergrad moving into the dorms and meeting my roommate for the time. Some of these contractual meetings end in friendship while others in enemies, I'm glad ours became the former. Over the following few years I'd come to consider him my best friend from undergrad. I had come to admire his intellect, his wit, his calm mind, and above all his inner child. He's one of perhaps five people who knows exactly what to say to put me in a great mood. Anyway . . .

Kalamazoo, MI
On July 9th, I drove from Milwaukee, WI to Kalamazoo, MI to attending the wedding of my best friend from undergrad, Jackson to Mandi. I had known both of them since freshman year of undergrad and it was no surprise to me that this would be the eventual outcome. Only death, dismemberment, or serious illness would prevent me from attending their day and celebrating it with them.

I arrive in Kalamazoo and check into my hotel before making my way to Stetson Chapel. I was glad to see Jackson's other friends - also my friends - as the best men and ushering in people. Oh how long it's been since I've seen all of them in one spot! The wedding ceremony itself was short and sweet without many bells and whistles. It suited the both of them perfectly.

Stetson Chapel.

The lovely Mandi.

After the wedding ceremony, we had about an hour to kill before going to the Fetzer Center at WMU for the reception. Several of us decided to hang out at a nearby Starbuck's for that time. The reception hall was very nice and I'm always amazed at the food they serve at weddings. After a period of time, the whole wedding train made their way down the stairs, with Jackson and Mandi addressing the populace briefly, before making their way into the dining area.

Jackson & Mandi addressing the populace.

Jackson in one of his classic poses. This is why I love the guy.

Their cake was quite delicious. Of course it was, Jackson had his hand in picking it. I would trust his palate with (almost) all dessert items, lol. I do believe I had a second slice later in the evening after everyone had been served. They also had the nice (and cute) idea of having a cookie bar towards the end of the evening - huge plus there, haha.

Their first dance. :-)

Others line-dancing. I didn't partake.

I'm glad I went, truly. And Jackson kept telling me how glad he was to have me there as I was (apparently) one of the few close friends he's made throughout undergrad. I guess it's likewise.

Me with Jackson, Mandi, and Sarah (going counterclockwise from me).

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South Haven, MI
The following day, I had to decide between driving straight back to Milwaukee or first stopping by South Haven, MI to spend more of the day with Jackson, Mandi, and others. I decided on the latter. Because I had gotten up early and had a huge chunk of the day to do whatever, I decided to drive to South Haven on my own first and explore around a bit. It's not something I normally do (or normally like doing) but hey, I have the time, so why not?

Driving into South Haven, MI.

I decided to have lunch there. I went online and found a nice little place called the Chocolate Cafe. I got one of their signature mocha (which was delicious) and a Tuscan chicken wrap, also pretty good. After lunch I decided walk around town and down to the beach while I waited for them to arrive. It was easily 90+ degrees outside, but it was still somehow nice.

Chocolate Cafe.

Along the South Haven Riverfront out to Lake Michigan.

Lighthouse!

Pirate ship!!

Looking back at the South Beach.

Soon Haley, Adam, Katie, and Geoff arrive at the South Beach and I join them shortly. Jackson and Mandi arrived a little while later.

I was clearly not dressed for the occasion, and so stayed on the beach.

Jackson, the beach ninja!

Friends! Haley, Adam, and Katie (left to right).

This is how you tell they're married: they assume the same stance. :-P

After a couple hours on the beach, we decided to head back to town for a light dinner. We make our way to Clementine's. It was really good. I wish I had been hungrier and tried more of their food, but oh well. Maybe next time. It was a great end to a wonderful day with old friends. :-)

Backlog: 07-09-11 to 07-10-11

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Medicine: Hit the Ground Running!

Physician 2 by ~stitchxwitch on deviantART

Time flies when you hit the ground running, and oh boy did I hit the ground running! I began my medicine rotation at the beginning of this month right after July 4th. I'm currently finishing up my first rotation site at the end of the next week.

Right now I'm still on the hospitalist team. This experience has been amazing in so many ways. First, the "amenities": at this rotation site, my day begins at around 8am and finishes whenever I complete my work (usually between 3pm and 5pm). We admit patients to our service everyday and so there is no call - which is amazing. But the best part of this site is working with the hospitalist one-on-one and his/her physician's assistant (PA).

The hospitalists give med students a ton of responsibility and independence starting on day 1, which is exactly what I wanted and needed (and secretly feared, haha). On day 1, I remember I had to take a full history and physical (H&P) on a patient who was newly admitted, all by myself. And then I had to present the case to the hospitalist, come up with a differential diagnosis, and a treatment plan. On day 2, I checked up on my patient (pre-rounded) before the hospitalist did, presented my updates to the hospitalist, and wrote a medical note. By the end of the first week, I had done many of the things that interns in residency would be doing - examining the patient (doing the H&P), writing notes, coming up with an assessment and plan for the patient, writing orders (these had to be signed by the hospitalist, of course), and calling consults if the patient's problem was too complex for our team alone. And I did all of this mostly by myself. For the first time in med school I felt like I was really doing what I would be doing for most of the rest of my career.

And I had some great patients from whom I learned a lot of medicine. My first patient came in with congestive heart failure, my second with Crohn's disease, and my third with a UTI that lead to SIRS and subsequently sepsis. And by the middle of the second week, I had call consults from plastic surgery, gastroenterology, cardiology, and neurology services to come see our patients and advise us. Again, all of this pretty much by myself and at my discretion (of course I had to make sure the hospitalist, who's overseeing me and my patient, agrees). I loved feeling like I was actually contributing to my patients' care and helping them get better.

I honestly couldn't have asked for a better experience. Yes, it was intimidating at times, especially when my hospitalist basically says to me, "We have a newly admitted patient. Please go see him/her, start doing what you think should be done, and tell me what you think." And yes, it can be difficult answering the hospitalist's questions since I'm still trying to figure out what is the most important info to know, clinically.

The hospitalists change every 2 weeks or so, and by the end of my first 2 weeks, the first hospitalist I had been working with complimented me on my improvement from day 1 to when she went off service. I had started as a freshly minted M3 student, fumbling around and almost scared of making mistakes. And in less than two weeks, I had become more confident and comfortable around patients, working with them, and doing what I thought was necessary to help them. She was so happy by my progress that she offered to write me a letter of recommendation for residency, when the time came. That is, quite honestly, one of the highest compliments an attending physician can give to a med student - and I felt quite honored.

I hope that I can keep up this momentum and continue to improve over the course of this academic year, to learn from all of my patients and to help them. This is, truly, why I decided to do medicine.

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Wedding of Two Worlds

Last summer, Jim, one of my anatomy labmates, got married. This summer, Ritu, another one of my anatomy labmates, got married.

A couple weeks ago, Megan and I drove down to St. Louis, MO for Ritu's wedding. The drive down was pretty smooth, only narrowed down to 1 lane a few times due to construction (grrr). Her relative lives in St. Charles near St. Louis, so we first stopped by there since we were staying there Friday night.

Friday
Mehendi Ceremony
Friday night, Megan and I attended the Mehendi Ceremony where the women got henna done on their hands. Ritu was present in a really nice purple sari. There was tons of food at this ceremony, and there were still 2 more meals provided the following day! It was all so good, a mix of Americano and Indian.

Ritu's henna.

Saturday
Christian Ceremony
The day started off kind of rough. First the power went out at Megan's relative's place due to a ridiculous storm the night before (that also woke all of us up at like, 5:30am). But we got ready on time and headed out a good 15-20 minutes earlier than needed. Except that the highway I took narrowed down to 1 lane and we were stuck there for 15 minutes or so. Sigh. I took the first exit off the highway to cross a bridge only to find that bridge demolished. So I went back on the highway and after that point, it was quick driving. We arrive at Washington University with 5 minutes to spare. But the parking garage was closed! I frantically drove around and quickly found free parking.

We made it into Graham Chapel just in time. Good thing the wedding didn't start for a few minutes anyhow. Phew! The wedding was pretty nice. It lasted maybe 40-45 minutes. The flower girl, Markus's (the husband's) niece, was adorable! After this wedding, we went to the Marriott Hotel by the airport for the rest of the day's events.

Adorable flower girl poses.

Just married!

Hindi Ceremony
Later that afternoon was the Hindi ceremony. It was held in an outdoor tent - most amazing tent I've seen, it even had AC! Both Markus and Ritu looked stunning. There was a Hindu priest officiating the ceremony who took breaks to translate what was happening (also, a handy little booklet was provided to explain things). This ceremony lasted much longer, a tad over 1.5 hours.

Statue of Ganesh.

Reception
Soon following the Hindi ceremony was the reception. The food, as always, was buffet style with Americano and Indian options and pretty much all of it was amazing and delicious. I only took a little bit of everything and even so I was stuffed! Their cake was also really delicious. After eating a small slice of the vanilla part of it, I couldn't finish the tiny slice of chocolate (I normally don't like chocolate cakes much, but this one was outstanding). I ate so much I could barely move, lol.

Markus, Ritu, Megan, & me

Sunday
Shaw Botanical Garden
Megan and I stayed in the hotel over Saturday night. We packed and hit the road back, but not before seeing a few of the sights in town. The first place we stopped by was the Shaw Botanical Garden. We arrived early in the day so it wasn't too hot and humid out yet. We had a great walking tour of most of the gardens by our tour guide, Norma.

The Hill
After walking around the gardens for about 2 hours, we started getting hungry and headed over to The Hill district for lunch. It's a very Italian area and we failed to realize that most establishments there don't open on Sundays. We did eventually find a pizzeria that was really good and had some yummy gelato afterwards. :-)

Gateway Arch
Finally, just before heading out, we had to stop by the Gateway Arch, perhaps the most iconic symbol of St. Louis. We didn't go to the top but just took pics around it. It's so much bigger than I thought! All in all, it was a great trip packed into a little over 2 days.

Backlog: 06-17-11 to 06-19-11

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