Hi Nat!, I'm like GED2MD in the respect that I too go through withdrawls when there isn't a recent post from you, then I wonder, how's she doin', she must be buried with work, adjusting to your new role and getting situated with every new rotation, and then yeah!!, a new post! Oh man, this last one just got to me. Sometimes just simple, descent acts of kindness can do so much more for the human spirit than all the book knowledge and technical wizardry that we must absorb for our careers. I can't thank you enough for sharing your experiences with us. Vita (in Milwaukee)
Hi Folks,
Today I spent the whole day in the Breast Oncology Clinic in the Cancer Center here. My attending physician is pretty neat to work with. I have learned how to perform a very thorough breast exam and detailed history with risk assessment.
Today, we had four ladies request bilateral mastectomies. Three out of the four are under the age of 45, which blew my mind. Before I started this clinic, I used to think that breast cancer was the end of the world as I know it. After meeting and working with some of the women today, I have seen so many great examples of courageous women who are truly “living with breast cancer”.
One of my patients was a very beautiful lady who was under 45. She looked as if she stepped out of a fashion magazine but she has a very large breast tumor that is rapidly growing and quite invasive. She has been reading almost every piece of information on breast cancer that she can find. It is great to have an informed patient who wants to discuss treatment options. Even though her treatments are limited, she has a very clear idea of what in store for her in getting past this diagnosis and on with her life. Our clinic is full service in that we work very closely with oncologists, genetic counselors and psychologists and psychiatrists to ensure that our patients have comprehensive care. We have our own set of radiologists and pathologists who also consult with our patients. It is neat to see the team approach to medicine.
We also have provisions for patients who want to research alternative and complementary medical treatments for breast cancer. We encourage patients to investigate all areas of treatment and make informed decisions. My attending physician keeps very current on the literature and can provide almost any rationale for breast cancer treatment complete with statistical verification. He is a maste of evidence-based medical practice. Again, he makes me take my level of practice up a couple of notches. He is a very young physician who is married to a physican and whose sisters are all physicians. Can you imagine the dinner conversations in that house?
I had several patients who were given very good news today. One lady cried for several minutes after finding out that her biopsy showed no evidence of malignancy. It is a great feeling to deliver good news sometimes.
I really get a sense of my own mortality dealing with this clinic. Most of the ladies in this clinic are my age and have been very healthy. If I were diagnosed with breast cancer, I would want to be treated by a physician who encouraged me to be proactive in my treatment scheme. Most of our biopsies are done in our out-patient surgery center. Our larger cases are done in the main OR because the patients have to be admitted post surgery.
Next week, I have a couple of very large cases to do with another of our Surgical oncologists. We have a joint case with the Vascular Surgery team, to remove a sarcoma from the thigh of a 48-year-old patient. The vascular surgeons will establish a by-pass in the leg and then we will resect the sarcoma which involves most of this patients thigh. Sarcoma is a malignancy of muscle tissue. This case should take most of the morning to complete with the patient going to the Thoracic Cardiovascular Post-op Unit after the case. I will be back in familiar territory on this one.
I have been taking care of a patient who is post-op liver resection for cholangiocarcinoma which is cancer of the bile ducts in the liver. His fluid management has been a nightmare but I have learned how to replace and keep up with a patient who is pouring several liters of fluid per day out of his abdominal wounds. It has been a challenge. I don’t want to sent my patient into congestive heart failure by overloading him but on the other hand, I need to keep his kidney’s perfused too. I can see why I am going to be pretty sophisticated with patient care at the end of this rotation! 
Nat
Hi folks,
This is one of those call days that you pray for as a Surgical Intern. I have a total of three patients in the hospital at present. I have finished all of my scutwork such as dictation and discharges and I now have time to do some reading. I try to read at least 30 minutes per day even if I am so tired that I can’t keep my eyes open. I have ABSITE in January and you can’t start preparing for this exam too early. I also have USMLE Step III to take too. The problem with USMLE Step III and surgical internship is that you can get far from medicine with all of the surgical hardware to get used to.
On Friday, my last overnight call day(yes, I am doing Q 2day call!), I had a patient in ICU to follow. He was a gentleman who had undergone a Low Anterior Resection for colorectal cancer at the rectosigmoid junction over 100 days ago at another hospital. About two weeks after his original surgery, he underwent an exporatory laparotomy and colostomy for leakage. He was subsequently transferred to our hospital where he underwent another ex lap and was found to have bowel contents throughout his abdomen. That being said, he now has been here over 70 days and has a enterocutaneous fistula. He has bounced in and out of various ICUs for problems like atrial fibrillation, renal insufficiency and acidosis, sepsis and other things. We had finally gotten him off mechanical ventilation and out to the floor for a couple of days last week when his metabolic acidosis that is secondary to his renal failure began to escalate. He was transferred back into the ICU, (MICU) for aggressive hydration and electrolyte correction. He was hypernatremic, hypomagnesemic and his creatinine was climbing. I had given him 5,000 ccs of fluid bolus on the floor over 8 hours and after measuring a CVP (after placing a triple lumen central line) I knew I had tanked him pretty well but his urine output was very low. Since I wanted the option of mechanical ventilation, he needed to move to the unit. I stopped the fluid bolus and placed him on the vent and asked for a renal consult to assist with the acidosis. I watched his urine output and ventilation pressures hourly and tried to walk a fine line between pulmonary edema and perfusing the kidneys while updating my chief resident on my management.
In the meantime, a trauma alert was called and I was sucked off to the emergency room to help deal with a 24-year old gentleman who had decided to get into a fight in his local bar, get whacked (under the strong influence of ETOH), got into his car and drove 50 mph into a tree. He was flown in by Pegasus and arrived with brain matter coming out of a very large anterior head wound. After getting him resuscitated and under the bright lights and cold steel of neurosurgery, I was alerted to the impending arrival of a transplant patient who would be receiving a kidney transplant.
I admitted the transplant recipient and got IV lines, history and physical, bloods drawn and other pre-op things done so she could be matched with the cadaveric donor kidney that had not arrived. By the time I finished getting this patient admitted, it was time for me to pre-round on my floor patients and get ready for rounds. I had literally been going the entire night but it felt like I had just arrived. The night flew by quickly.
So today (my next 24-hour call day), my renal transplant patient is coming out to the floor and doing very well. My patient in renal failure is happily hanging out on the ventilator after a spin cycle by the renal folks. He is still acidotic and dropping his heart rate into the 40s because his heart does not tolerate acidosis very well. My chief resident wanted to do another spin cycle but the renal fellow wants to wait a bit. My trauma patient is mechanically ventilated but stable at present. He has a long road ahead of him if he even survives.
So happily I am off to read about hepatobiliary surgery and acute renal failure. I have two more weeks on this rotation and I go on to colorectal surgery service (Blue team). I am going from Gold Service (Surgical Oncology) to Blue Service. I pick up my cross-cover patients (Green/Transplant) at noon today so I have some real relaxation time until I get signout. I will also spend some more time in the STICU looking in on the two patients that my service has in that unit. Since I have a STICU rotation coming up in January, I try to review my ICU stuff on a regular basis. The STICU attending physicians appreciate my initative in trying to learn as much as possible before I have to do the rotation. (Hint to the third- and fourth-year medical students)
Nat 
Hi Folks,
Well, yesterday I really felt like an official surgical resident. I did three cases with just me, a third-year medical student and the attending. My attending is our youngest breast surgeon so all of my cases were breast biopsies and lumpectomies with sentinal node biopsy. As the resident, my first duty was to greet the patient in the outpatient surgical staging area. After greeting the patient, I made sure that the operative permits, history and physical sheets were up to date and correct. I re-interview the patient to make sure they have not taken any aspirin and have been without food since midnight. I then have to mark the surgical site to be sure there is no mistake. I then turn the patient over to the anesthesiologist for IV start and their interview.
I head to the OR room and pull my gloves and my attendings gloves. I also greet the nurses and make sure that they have the proper instrument boxes and tools for the case. (Each surgeon has an instrument list that they review with us when we come on service.) I do any last minute reviews with the attending physican at this point. When the patient arrives in the room, I make sure that the patient is properly positioned for the anesthesia induction. I also put the SCDs (squeezers to prevent thromboembolism) in place and make sure the patient is totally settled on the gel pad. As the anesthesiologist is getting the patient settled, I scrub so that I can prep the patient.
After my five-minute scrub ( I recite Paul Revere’s ride from beginning to end so that I know that I have scrubbed long enough: " Listen my children and you shall hear, of the midnight ride of Paul Revere…"), I enter the OR and put on sterile gloves to do the site prep. At this point, my attending and the medical student will scrub. When he enters the room, I have prepped the patient. I am gowned before the student and after the attending. The attending and I will then drape the patient and set our positions. I am positioned across the table from the attending. We mark the site and I announce to the anesthesiologist that I am making the incision! The first time I did this, it was a cool feeling. I practiced holding each instrument and keeping my eyes on the incision so that I can put my hand out without moving my head. The scrub nurse follows my lead and I follow my attending’s directions about the procedure. The medical student gets to retract for me! I did so much retracting last year that I thought I was waterskiing at times. This continues until closure time when we allow the medical student to put in a couple of sutures for practice. I always signal the anesthesiologist that I am beginning to close the fascia so they can start waking the patient. I generally finish the outer incision on breast sites because the edges have to be lined up with the highest precision. I am very proud of the good subcuticular closes that I learned to do at Mayo Clinic. (My thanks to Dr. Geoff Thompson!) Dr. Brenin will pop his gown and return his phone calls. I dress the wound and get the final discharge instructions from my attending while the patient is awakening. The anesthesiologist, the medical student and I will move the patient to the recovery room. We are sure to thank the scrub and circulating nurses for their help.
The medical student will write the brief operative note while I write the discharge orders in the recovery room. I also brief the recovery room nurse about the operative findings after the anesthesiologist finishes his report. I also co-sign the student’s note and write the presciptions for the patient to take home. It is then time for me to dictate the operative report and repeat the whole process. Since these are pretty simple cases, the operative report does not take too much time. I repeat the whole process for the next two cases. When I am done, I have been operating from 7:30 am to 3:00 pm.
Some more funny little quirks during surgery: The attending gets to choose the music. In the case of Dr. Brenin, he chose a mixture of 70s and 80s rock. We spent most of the case guessing which group was singing.
The attending gets to tell the jokes and we get to laugh. If the room grows suddenly quiet, the case is getting intense. Dr. Brenin was trained in Breast Surgery at Columbia Presbyterian Hospital. He is very laid back and loves to teach so he is a good attending for me to operate with as I am pretty green at this point.
You don’t get lunch if you have several cases strung together. If the attending eats, you may be able to grab a quick bite but my job is to make sure that everything stays on time. OR time is expensive and we keep it to a minimum. We also want the patient under anesthesia for the least amount of time.
The OR lounge has every soft drink plus iced tea, hot tea, cocoa, and coffee for replenishing fluids lost while operating. We also have plenty of soft chairs with foot stools and phones so we can get our feet up to dictate our cases.
The choice of headgear is a point of individual preference as long as your head is covered and the cap is cleaned. (I have a very lucky surgeon’s cap that was a graduation gift from Mary Bois Byrne that I wear for all of my cases.) I also wear my lucky pearls at all times.If my pearls are not around my neck, they are around my shoulders but I always wear them! My trademarks are my lipstick and pearls for rounds and scrub! I also wear my little thin half-moon reading glasses and fluorescent green eye protectors! I always wear two pairs of gloves. I wear size 8 BioGel gloves under size 8.5 green gloves. I always wear the greens on the outside because the ties slip better for me.
Well, that’s my most recent update. At the end of this week, I am headed back up to Howard to cloak the incoming freshmen medical students. The speaker is former Surgeon General Jocelyn Elders. I will take a camera and get some shots with her. It is an honor to be asked to return to cloak and meet her even if she was a bit controversal in her advice on safe sex! 
Natalie
Hey Natalie,
I just wanted to add my thanks for your posts. They are both very interesting and motivational to me in my journey torwards med school. Keep them coming as you have time.
Thanks!!!
Damon
Hi folks,
Another month has passed and I have left the world of surgical oncology for ta-daaa!, Colo-rectal surgery. I am now on what is called the “Blue Team” for one month. I have been referring to myself as a “smurf” 
because it fits.
I started the service with 19 patients who have had some form of surgery on the colon or rectum. Most have rectal cancer and have undergone procedures that have left them with colostomies. I can’t wait to get into the details of the various procedures like low anterior resections and J-pouches. Most of my work today was just getting oriented to the service. Since I am post-call and it is Sunday, I was able to leave the hospital shortly after noon instead of the usual 7pm.
My biggest challenge this morning was getting adequate pain management for a patient who had an epidural catheter in place but had complications. My take-home lessons from my turn on Vascular surgery was that epidural pain catheters can play havoc with your post-operative management if you are not aware of their complications. In my case, the patient I was caring for, had a numb left leg. This was pretty unnerving for him so I contacted the Acute Pain Service of the Anesthesia Department and we came up with a strategy to offer adequate pain relief without the numbness. I made a mental note to read more about the exact placement of an epidural catheter in order to manage the complications better.
My third-year, assistant chief loves to teach so I am looking forward to getting some hands-on experience with procedures. I am even told that I will get to do a hernia or two in the OR. Getting to operate is worth every second of floor work. My fellow intern on this service is wonderful. Since I have been stuck with two marginal interns, sharing the service with Hilary is going to be a pleasure. 
Isn’t it funny that when there are two women on the service, the details just get taken care of and we are able to share the duties without problems? Hilary is going into Urology and is doing only one year of General Surgery.
It is nice to be in the abdominal cavity at last! While Vascular and Oncology were fun, the extremities and breasts get to be pretty routine. I will even get to do some Endocrine Surgery on this rotation. Since I did major Endocrine at Mayo, I am very comfortable with these procedures. This is going to be fun.
Last night, on my final night of call for the Hepato-biliary/Transplant Service, I had to get a bileloma drained on a patient who was post liver transplant. We ended up doing the procedure under Ultrasound. Again, Ultrasound films used to look like gray snow to me but now I can actually see enormous utility of this imaging technique. We ended up sucking about 2,300 ccs of bile from the patient’s abdomen. She thanked us profusely because she was more comfortable. I sent the fluid for gram stain and cultures just in case she was masking a peritonitis with her immunosuppressed state. The Gram stain reported out with no bacteria seen so I am a little more comfortable with the huge amount of bile that is pouring out through the Jackson-Pratt drain that we left in place. Bile is very irritating to the abdomian cavity so her pain level should decrease as we drained the bile.
Well, I am off to read about colo-rectal procedures. My reading should take most of today and tomorrow. I am getting to be a very boring person just reading and sleeping on my days off. 
Natalie
Hi Folks,
This weekend is Homecoming Weekend for UVa. There isn’t a hotel or motel room left in Charlottesville beginning Friday. Since I am not on call, I am going to head out of town. When our team is on call, we handle the traumas too so I am especially happy to be out of the hospital. It is not that I mind doing the traumas, I love them, but I am also covering the Orange Service (laproscopic and obesity surgery) where there are only a couple of patients but they are always sick. As soon as I am happily kneedeep in a wonderful trauma, one of the Orange patients will do something that requires me to be at bedside. I love the Orange team though. They are the nicest residents and I enjoy covering their patients too. 
This afternoon, I have a couple of endocrine post-ops coming back to the floor. My service, Colo-rectal and endocrine, is not too busy at this time. I have three patients left plus the two post ops. One of the post-ops is an adrenalectomy who has a history of DVT. He should be interesting to take care of. The other post-op will be an overnight then home in the morning. We can get her out of the hospital as fast as I can get her discharge orders into the computer. Since she is just overnight, I don’t have to dicatate her discharge summary. It’s put some discharge orders into the computer(it even prints my precriptions for take-home meds) and then let her go home.
The service is interesting. The clinics are long and many of the patients have MRSA or Meth-resistant staph aureus. The patients come into the clinic on isolation. I have to dress in a wonderful yellow gown to see them. At least putting on that isolation get-up keeps me warm. I saw about 10 patients in endocrine clinic yesterday and then finished up in colo-rectal clinic. The nice thing about the colo-rectal clinic was that there was catered food for the staff. 
This made clinic even more fun!
The most useful thing that I have learned to do is hunt-down the radiology resident to read my films. I can usually “sweet-talk” the radiographers into shooting my patients (I buy them lunch with my meal cards) but getting the films read is always a challenge. The radiographers let me in on their hang-outs read “hide-out” so that now I can get my stuff taken care of. The first lesson of residency is make nice to the radiographers. They can make your job very easy and they will get your stuff read for you if you really treat them well.
The other folks that help me out are the enterstomal care nurse and the nurse practictioners for the individual surgeons. They can really help get patients out of the hospital and into Skilled Nursing Facilities or SNF (pronounced “sniff”). Since they don’t operate, they have plenty of time to work on the details of getting all of the information that must go with the patients to the SNF. The NPs also know the quirks of the surgeons so they can help you avoid trouble before it starts.
Well, I have to check on a post-op and do some reading. I have already been to the OR so my work is almost done for the day. Yesterday, we did evening rounds on four patients and took almost three hours. It was painful for my fellow intern who had a dinner date but I was post call and pretty numb. My chief resident was in the mood to teach and I enjoyed his pearls of wisdom especially the ICU stuff.
Later,
Natalie
Hi Folks,
Yesterday, I managed to log a full day in the OR. My assignment was to “bird dog” my attending physician which meant that I would be able to log any of his cases. To log a case means that you get to get credit for it. While I am a junior resident, meaning that I can’t log the big cases such as Abdominal perineal resections or sigmoid resections as a junior surgeon, it does mean that I can log the junior-level cases. To this end, I bagged a laproscopic cholecystectomy and the laser excision of perineal warts. Now, I know what you are thinking! 
How could lasering off b— warts be fun? The fun part of this case was getting to use the laser.
The first patient had Bowen’s disease. She was 34 years old and was post hysterectomy as a result of suffering from this terrible disease. My attending and I were able to burn the lesions so that she would have an easier time. The problem with this procedure is that in this area, the perineum, pain control after surgery can be pretty difficult. For the procedure, we had to wear special laser surgical masks and space hoods. It was pretty cool. We were also sitting which is quite rare for most surgical procedures. We used wet sterile towels instead of the usual drapes because the laser will burn drapes too. The whole procedure took about an hour.
My next patient was an inmate from one of the correctional facilities. He had been suffering from gallbladder disease and was scheduled for a laproscopic cholecystectomy. As a medical student, your main job in a laproscopic procedure is to drive the camera. As a resident, your main job is to do the procedure under the direction of your attending. The first thing I did was get used to how the instruments worked. There are graspers and clippers and the camera.
After scrubbing and getting the patient prepped, my attending showed me where to place the ports. My patient was a thin gentleman but had skin like elephant hide. He had been working out in the gym and was at tight as a drum. It was difficult to get the trocar into his abdominal cavity so that we could pump in the carbon dioxide. After getting the gas in, we placed ports for the graspers, the camera and for the scalpel. The first thing I saw was a shrunken cirrhotic liver. This meant that bleeding could be a problem so we took extra care to make sure that we didn’t disturb the liver.
It wasn’t difficult to see the gallbladder! It was huge and filled with stones. We put in an instrument to decompress the distorted organ (we just drew some of the bile out with a large syringe). I then grapsed the gall bladder in two places and held it against the abdominal wall while my attending physician gently excised it with the cautery scalpel. The next task was identifying the common bile duct and cystic artery. Again, the anatomy looked like Netter’s because we were able to identify these structures after teasing some of the fascia away from them. We put clips on the artery first and ligated it. Next, we put clips on the cystic duct and ligated it. The rest of the surgery was gently freeing the gallbladder from its bed under the liver without disturbing the liver. After the gallbladder was free, we stuffed it into an instrument with a bag on the end and attempeted to remove the bag and gallbladder. We ended up making the umbilical port incision larger because the gallbladder was so full of stones that it would not pass easily through the incision that we had made. After removing some of the stones, we finally got the huge structure out through the small incision in the umbilicus. My attending took a good look around the abdominal cavity to insure hemostasis and then we began the closure.
After my attending closed the deep fascia of the larger umbilical incision, I closed the port incisions, the largest one was about 2 cm, with interrupted subcuticular sutures. Before I closed the skin, I injected every incision with marcaine, a local anesthetic, so that the patient is more comfortable for the first eight hours post-op. I am very comfortable with this type of closure now. I put steristrip and primapore dressings on the small wounds. The patient was taken to the recovery room where I wrote his prescriptions and post-op orders. I usually explain any problems to the recovery room nurse so that she can make sure the patient is fairly pain-free while recovering from the anesthetic.
After a quick dictation, I found my next patient in the surgical admissions center or SAS. He is a 61-year old gentleman who was undergoing a sigmoid resection for cancer. He had preoperative cardiac problems so the anesthesiologist was carefully reviewing his cardiac pre-operative evaluation. In this room, the anesthesia resident is a fellow Howard graduate so we have a great time chatting about the old school over and in-between cases. I knew that would be shifted on this case so I prepped the patient, and left after the prep. My chief resident did this case.
I moved over to the abdominal perineal resection case. This was a case of a 60-year-old lady with a sarcoma at the rectal-vaginal junction. Again, this is a senior level-case but my third-year resident needed an extra pair of hands for this case. Since my attending physician had two rooms going, he started the other case with my chief and another attending started this case with me and my third-year resident. There was also a medical student too. We removed the rectum and I scrubbed out after this point, to help my fellow-intern take care of floor duties and get some of the post-op work done.
I was able to write post-op orders on a couple of the thyroidectomy patients who would be coming to our service. We also admitted a patient in through the clinic who was post-hemicolectomy so I got to write his admissions orders and get him into the CT scan. By this time, I was able to write post-op check orders on the thyroid patients and check some of the floor patients. We did evening rounds and I got to leave the hospital at 7pm. I gave one of the medical students a ride home. She is fluent in Spanish and agreed to help me with my medical Spanish.
Another wonderful day in the life of a surgical intern. I entered the hospital at 4:45 am and left at 7:00 pm. If I had been the call intern, I would have either stayed overnight, covering the Orange service in addition to my service with six fresh post-ops and seven admissions plus the admissions from Orange and the traumas. I enjoyed every second that I spent yesterday operating and writing orders. I learned how to manipulate instruments through the laproscopic ports (not much different from playing Pac-Man or Galaxian) 
Natalie
Nat, this time when I read your description of surgery, I can relate on an experiential level - very exciting! I was the medical student driving the camera on the lap chole from hell two days ago - although the patient had only had biliary colic symptoms for two weeks, her gall bladder was big, with a thick but friable wall, and adhesed in a LOT of places to the liver. It eventually came out without converting the procedure to an open cholecystectomy but damn it was just horrible. About two-thirds of the way through, my attending said, “You know, I am just not having fun any more. This is WORK.” Meanwhile I was terrified because I am not a good video game player and so my role with the camera was really going out on a limb for me. I think I did okay.
Yesterday I saw a thyroidectomy where the thyroid was so big that the attending jokingly gave it an Apgar score. Lotta blood and a lot of retractor-holding for me and my fellow student. The woman’s thyroid had grown to the point where her trachea was deviated - the attending took a lot of pictures and anesthesia did a lot of worrying!
I am on the team that is supposed to be the “easiest” but this week, my colleague and I scrubbed in on more procedures than any other of the third year surgery students, and we did follow-up on more patients too. It IS exhausting - up at 4am, in the hospital 5am to 7pm, 45 minutes to get home then a quick dinner and a little reading before hitting the sack. Only frustration with all this OR time is that we aren’t getting floor time to get to know the ins and outs of labs, radiology etc. But it is fun and hopefully the schedule will calm down a little soon - one of the two attendings on my team was on vacation, plus the GW OR was down for several days surrounding their move across the street, so the surgery schedule is kinda full.
My two personal victories are that 1, I have been able to stand being on my feet all day, and 2 - fanfare: I lost two pounds this week! Surgery is a tough way to do it but I AM eating - just too tired to be very hungry. And I need to lose, um, probably 30 more so I’d have to stay way past my eight-week rotation for the Surgery Diet to really work. But I’ll take it.
Keep the stories coming!
Hey Mary,
I told you surgery would be fun! My number one rule on any laproscopic procedure is to personally thank the camera person. Driving the camera is almost as thankless as the endless “waterskiing” that medical students are sometimes called upon to do. I also appreciate it when the medical student takes the initiate to write the brief op note. That gives me a precious extra five minutes to get the case dictated and back into the theatre to prep the next patient. Just remember PPPSAFFED if you don’t remember the order: Pre-Op Diagnosis, Post-OP Diagnosis, Procedure, Surgeons, Anesthesia, Fluids (In, Out)Findings, Estimated Blood loss)and Disposition.
Glad to hear that the diet is working. Beware of the Surgical Colon. (No folks, this is not surgical Pathology to be removed) If you have one, you will find out what I mean! It is the opposite of Surgical Bladder
Natalie
| QUOTE |
| Glad to hear that the diet is working. Beware of the Surgical Colon. (No folks, this is not surgical Pathology to be removed) If you have one, you will find out what I mean! It is the opposite of Surgical Bladder |
LOL oh yeah I am definitely keeping that in mind! If I don't eat anything else for dinner I make sure to have my vegetables, har.
One of us students usually does the operative note - all this stuff that seemed incomprehensible just Tuesday is getting to be second nature already - that's the benefit of having been in the OR soooo much during just a few days.
And my teammate just called after completing her call night to say "we've sent everyone home, just show up for surgery at 7am tomorrow," yee-haa, I can sleep til 530!!
Last bit o' cheery news; my big sib knows our resident and just went on and on about how terrific he is - which I was already learning but it's nice to think he won't turn on us
| QUOTE (njbmd @ Sep 7 2002, 12:08 PM) |
| Hi Folks, I gave one of the medical students a ride home. She is fluent in Spanish and agreed to help me with my medical Spanish. Natalie |
Hi Natalie,
If you are trying to improve your spanish there is a monthly publication called El Puente which may be helpful. It's a magazine with current articles written in spanish with an spanish to english glossary on the side for key word. It covers current events and has a medicine and health section. It's a great way to build vocabulary and comprehension. See the website ED NEWS for details.
Damon
Hi Folks,
My Colorectal & Endocrine rotation is winding down. I will leave the world of the bowel for the thorax! I am looking forward to doing a stint on the Thoracic service because I cross-covered that service when I was doing my Vascular rotation.
Last Saturday night, I started the evening with an exploratory lap for what we thought was going to be a small bowel obstruction. We had attempted to get a small bowel follow-through study but the patient was too unstable and we needed to get moving. We were hoping to treat him medically with IV fluids and NG tube decompression but to no avail. On to the bright lights and cold steel of the OR.
I got to start the case with my chief resident and attending. The chief resident handed me the scalpel with a #10 blade and I made one long incision from his xiphoid to his pubic bone carefully going around his umbilicus. I used the electrocautery to bluntly dissect down to Scarpa’s fascial layer. I carefully cut through this layer with the electocautery placing my finger between the swollen loops of bowel and the electrocautery. I used the pennate pattern of connective tissue fibers in the linea alba to stay exactly in the midline and avoid muscle tissue.
When I opened the abdominal cavity, loads of ascitic fluid poured out covering the field and my shoes. I used a pool suction to drain out about 2.3 liters from his abdominal cavity. After we got in, my chief took over and he and my attending physician ran the length of the small bowel. This man’s abdominal cavity was caked with cancer tumors. His omentum contained as much cancer as fat. This is called carcinamatosis and is common in patients with metastatic lung, ovarian, colon and brain cancers. We found that his small bowel was hugely swollen from inflammation and contained no obstructing tumor. His liver had several fist-sized tumors.
After placing a gastric tube for decompression, we closed the abdominal cavity. My chief resident let me close the fascial layer and then close the skin with staples. This was my first case where I opened and closed completely. I used a simple running suture to close the fascia using a lap sponge to protect the swollen bowel and a malliable retractor for more protection. I then stapled my long incision closed taking care to approximate the edges carefully.
Just as we were getting ready to close the fascia, the trauma pagers went off. My attending physician scrubbed out of the case while we were closing the final staples of the incision. He went to the ER while I got the patient transferred to the STICU and placed on a mechanical ventilator. I quickly got the post op orders into the computer and then headed down to the ER to join my chief resident and attending physician.
The trauma patient has been flown in by Pegasus from another hospital. He was a 77-year-old gentleman who had gone face first through a windscreen. Almost every bone in his face was broken. He was transferred to neurosurgery and plastics divisions as he had no internal injuries.
I went back up to my call room and was beep out for another trauma about one hour later. This time a 34-year-old gentleman was hit on the head with a baseball bat as he had attempted to break into a church. One of the church secretaries had beaned him and then called 911. He reeked of alcohol. He had no intercranial bleeds and got a night in the hospital with two police guards.
Two hours later, another trauma patient who was 45 years old. This gentleman was walking with a group of friends after a long drinking spell in a bar and fell over a stair railing and down a cinderblock wall. He had managed to scalp himself on the way down. He was using profanity and bleeding over us. When he started to expectorate, I put a mask on him and continued to wrap his head in Kerlix gauze so we could get him into the CT Scanner. We scanned his head, chest, abdomen and pelvis. He had no injuries other than a very large scalp wound. I was literally looking as the white bone of his skull. Plastic surgery took him to the OR for repair. The last thing I heard him say was that he didn’t want his f–k--g hair shaved. Well, he looks like Michael Chickalis of Shield. He also has one huge headache too.
By this time, it was time to pre-round on my floor patients. I was happy to see my very stable patients who only needed quick morning checks. By the time my chief resident got in, I had everyone tucked in for the morning. I had a quick breakfast and headed home for some good sleep. I have one more night on trauma call before the month is out. It is a Friday and I hope it is not as busy as the last Saturday.
Natalie
Hi Nat, Your updates are better than watching tv. Man, surgery is just the best! Thank you for taking the time to put so much detail in your posts I feel like I'm right there. Best Regards, Vita
Your posts are the best Natalie. I was starting to have withdrawals. Look forward to more as you have time.
Hi folks,
Today, I finished four cases and ended up sitting in the PACU (Post Anesthesia Care Unit) with tears streaming down my face as I entered post-op orders for my last patient of the day.
My day started very early with an emergency call to the OR to finish a lap chole with one of my favorite attendings. I had worked with Dr. Craig Slingluff when I was on Gold Service and I was happy that he wanted me to assist with this case. Dr. Slingluff is the author of the Melanoma chapter in the lastest issue of Sabiston’s. He is a very young surgeon and consumate researcher. It is neat that he takes General Surgery call so I can get a chance to do a case with him. The lady was a 34-year-old mother whose gallbladder was easy to remove. When I rounded later in the afternoon she was preparing to go home.
My second case was an iliostomy takedown and hernia repair. This case went without any problems except we had to use vicryl mesh to get the abdomen closed. This lady had previously developed a couple of fistulas and had been hospitilized in the SICU with peritonitis. At this point, she was about six months out from her bout with peritonitis. The large amount of infection that had ravaged her abdominal cavity six months ago, made figuring out her anatomy difficult because of the adhesions and distortions. We were able to take down the iliostomy and close everything.
My third case was a sigmoid resection which just involved removing a portion of the colon. This case went without difficulty and the patient happily ended up in the PACU and later on the General Surgery ward.
My last case of the day was supposed to be an Abdomonal Perineal Resection in a 44-year-old gentleman who had a rectal tumor. This was a young man that had presented with rectal bleeding which after a workup, revealed a tumor that was about 4 cm from the anus. Since this tumor was so low, we knew that we would not be able to spare his rectum by doing a Low Anterior Resection. The tumor margins would not be wide enough.
The first thing that we did was suture his anal opening closed. Next we marked two possible locations for the colostomy that he would need after the tumor and suitable margins were resected. We opened the abdomnal cavity as was customary with a very long midline incision that went around his umbilicus. When we moved the omentum and ran a hand along his liver, we discovered several large tumors in the liver. We took a quick biopsy and further explored the liver which yielded several larger tumors. At this point, my attending elected to close the abdominal incision, re-open the anal opening and do no further surgery. Instead of a 3-hour surgical procedure, we were done in about 45 minutes.
After we settled this patient in the PACU, we went out to speak with the gentleman’s wife who was sitting alone in the Surgical Family Waiting Room. She just seemed not to grasp that her husband had inoperable metastatic rectal cancer. She just answered out questions with simple Yes or Nos. My attending physician called the family physician who had discovered the rectal tumor. She told us that the wife and husband are extremely close and that the wife bordered on hysterical when she learned that her husband had rectal cancer. After learning this bit of news, we sent our nurse practicioner back to the waiting room to be with the wife while we headed for the PACU to speak witht the patient.
Our patient is a very young, very attractive 44-year-old father of a 10-year-old son. He was fully awake and sitting quietly on a stretcher in the huge room. He wept uncontrollably when my attending physician told him about the rapid spread of the rectal tumors. He just kept asking how much time would he have with his wife and son. That’s when I lost it. This was the first time that I have cried in front of a patient. He was holding onto my arm and I could not hold back the tears. When I looked around, my attending was holding his other hand with tears welling up in his eyes too. This was the saddest day that I have spent at University of Virginia Medical Center. We just don’t have too much to offer this patient in terms of treatment for his advanced rectal cancer.
In the days to come, I am going to have to take care of him post operatively on the floor and in the clinic. We are going to have to help him prepare to die at age 44 and leave behind a beautiful family. 
Natalie
O Nat…
This job is damned sad sometimes. This may be the first time you've come to tears with a patient, but I know it won't be the last. Because it's so clear that your heart is in this for real.
Lots of times, the patient will be around for not too much longer, but the family is left behind to deal with years of reliving memories of the end of life story of someone they love. They will always remember the kindesses and the real empathy that you bring - and it will help.
Hi Dr.Belle,
That was a very sad post about the 44-year-old with metastatic rectal cancer. I know this may be reaching especially for a pre-med, but do you think this patient might quailfy for the clinical trials currently being conducted at NIH for patients with primary cancers that have metastasized to the liver? They are currently recruiting patients and he may quailfy.
For me, situations like this are going to make it especially hard to be a Physician/Scientist. I always ask the question when do you give up and who gets to decide? The doctors, the patients, the patients family? Tough questions I know, but I also think that everyone has the right to die on their own terms whether it be to discontinue chemo, or try the latest new treatment protocal. Very, very difficult situations indeed…
Kim
Hi Folks,
I wanted to update on my 44-year-old patient with metastatic rectal cancer. For the past two days, I have been helping him recover from the midline abdominal incision that we made in doing his exploratory laparotomy. He has done very well in his recovery. He and his wife have been very positive about getting into the next phase of his recovery and treatment. I can’t praise my attending physician enough because he has referred this patient to an oncologist who has lots of experience with clinical trials and is very hooked into NIH. While my attending physician just shudders at the extent of the cancer, he does not give up hope that medical oncology may offer something that may help this patient. An extensive radical cancer surgery simply is not the answer at this point.
I have taken as much time as possible to listen to what my patient and his family have to say. Sometimes listening and being there is the best medicine that we can offer. He knows that he has the fight of his life ahead but he is determined to have a good quality of life and be around as long as possible for his wife and children. They all seem to have a very tight bond and lots of hope for putting up a strong fight. I have learned so much from just having the opportunity to meet them and assist in his care. They are extraordinary people and I will be a little sad to see them leave the hospital today but my prayers will go with them for living the best life that they can. They have promised to keep in touch to let us know how they are doing with the oncology phase of his treatments.
I can’t say too loudly that even in the face of being pushed to the limits on call, responding to trauma after trauma, being rung out physically and emotionally, it is meeting and caring for people like this gentleman and his family, that make this job, the best in the world. 
Natalie
Nat,
Your posts are eloquent, inspirational, and educational. Thank you for taking the time to share your journey with us.
Melvin Konner's book, Becoming A Doctor has a poignant section about the advice the author recieved about dealing with seriously ill and dying patients. (The author was a non-traditional student, Harvard professor, PhD in Anthropology, spent 2 years observing the !Kung in sub-Saharan Africa, and had a tough time with his training, as he felt the practice of medicine was dehumanized.)
The advice was that, for dying patients, the best thing that you can do is just be there for them. Sit and listen. For they know what they are embarking on, and just need someone to talk to. Konner later had some experiences that shored up this gentleman's advice.
It sounds like you're doing that already. You're a good doctor, Dr. Belle.
Glad he's getting hooked up with some NIH trials! I worked with a woman who spent 10 years fighting ovarian cancer that metastasized. She succumbed to it last year, but with the help of the NIH trials she was in, I watched her go to Morocco, Egypt, and other countries, working to improve women's reproductive health. The prolonged her life, with a relatively high quality of life, and I don't know that I could ask for anything more in such a situation.
Keep on truckin'.
cheers,
Vera