moment of the day

Context: Discussing the one-complication-after-the-next Whipple procedure we performed yesterday.

Student: I'm not exactly sure, but I thought I saw a spleen in the trash at one point during the operation.
Doctor: Ah yes. Another complication of surgery.

Not amusing in the sense that Mr. yellow lost his spleen due to a surgeon's hand slip. Amusing in the sense that I immediately pictured informing patients that a rare but disturbing side effect of their coming surgery is spleens spontaneously appearing in trash cans.


On a related note, after surgeries of this ilk, patients often have to be fed initially through a tube directly into their small intestine. Our head surgeon absolutely insists that when this was first done in France the meal of choice was eggs, cheese, and wine. We of course were dubious as to the legitimacy of this, but he insisted that it was not only true, but actually logical. Eggs and cheese for calories and protein. And the wine? "It goes well with breakfast. And helps with depression." Exact quote.

today . . .

I scrubbed into a Whipple procedure.

A gallbladder exploded on me.

I got a bikini wax.

How was your day?

Our hospital has magic tubes! Every room has a pipe with a small opening that travels up through the ceiling. You stick blood vials/lab orders in glass capsules, pop them in the tube, punch in a room number and the capsule magically zooms through the walls of the hospital and is plopped down in the room you sent it to.

I adore the magic tubes.

Or I did until 1:44 am Tuesday night.

Let's go back. . . I had been in the hospital since 7:50am, awake since 5am. It was my first night in the surgical side of the ER. (Israeli hospitals have multiple emergency rooms: surgical, internal, gynecologic/obstetric, and pediatric). And the ER was jumping.

The on-call surgeon has a teeny little office in the middle of the ER. Israelis are tougher than Americans, so instead of being wheeled in, or waiting in beds, they walk themselves on in to the office and then the surgeon decides if they're sick enough to need a bed.

Now- the little tiny surgery office closet is also home to the ER's only magic tunnel. Which means that about 7 times per interview the machine makes various groaning and clunking sounds and then loudly gives birth to a tube filled with lab results. And about three times per interview a nurse or doctor will run in, throw some tubes in a capsule and send them on their way, a process which makes about the amount of suctioning noise I imagine is necessary to vacuum seven to nine 747s up the tube.

This was fascinating and delightful to me for about the first hour.

Some of my favorite calls of the night:

Mr. M, a 30something Ethiopian immigrant who drank two liters (yes, two liters) of all-purpose kitchen cleaner. "The lemon flavored one," the nurse made sure to inform us. He entered the ER yelling and flailing and making as much of a scene as possible. This disturbed the surgeon, who clearly prefers anesthetized patients, so I was given the job of getting him to calm down and finding out exactly why he drank two liters of kitchen cleaner.

The calming down part I never really succeeded, but he readily volunteered that he drank the kitchen cleaner because he wants to die. "Why?" I asked. "No happy in tummy."

The orthopedist who happened to be walking by quipped: "well at least it's clean now."

Heh.

My favorite patient of the night was a 19 year old girl who'd been bitten on the lip by her Pekinese. She was unvaccinated. Her dog, all vaccinations up to date.

The facial surgeon took a look and advised that she get a few stitches to align her lower lip. She asked if needles were involved, we explained that it's difficult to insert stitches into skin without something sharp and pointy being involved but that we would numb her and she'd only feel one prick. She panicked, refused the stitches, and tried to get discharged. Her father literally dragged her back and said that she had to have the stitches because she was way too pretty to mess it up with a scarred lip.

After about 15 minutes of arguing she reluctantly agreed, and cried and screamed and squirmed through the entire procedure. Halfway through her father goes: "you didn't make this much of a scene with your breasts." Turns out, little miss terrified of needles has had two elective breast enhancements (they didn't turn out big enough the first time).

The thing that's the strangest to me about all this is that daddy payed for two breast enhancements, and vaccinated his dog, but she has received zero of her scheduled vaccines.

People are special.

What you don't know. . .

The promised article:
Do you know who's been in your vagina recently?


This is a tough one for me.

Because if I dig deep down in my heart and soul, I have no problem, whatsoever, with students practicing exams on unconscious patients. None at all.

It's not something we do here in Israel as far as I know. But, we did learn how to draw blood and insert IVs during our internal medicine rotation, and if we were feeling nervous we were often directed to the intensive care room to practice on the most sedated, senile, and least-likely-to-feel-and/or-respond-unfavorably patients. It makes sense. We're inevitably going to cause pain with our first clumsy attempts to insert needle into vein. Practice on those who aren't going to scream, refuse, or suffer the mental anguish of my 20 minutes of blood-drawing ineptitude. (I was shaking so much the first few times I couldn't unwrap the needle without getting the wrapper stuck to my glove, tearing my glove in the process of removing wrapper, and then knocking something over, such as a lamp or a wandering patient.) It's best to spare patients the mental anguish of an encounter with untrained, terrified, needle-wielding me.

And now, during surgery, I touch people's intestines without consent, I learned how to do stitches yesterday on a real patient without his consent. (Big busy surgeon demonstrated one stitch, handed me the needle, said "do the rest," and left. I couldn't leave the poor guy open!)

But of course I see the other side. I understand patients' wierdness about having a bunch of students up in there. I agree 100% that patients should be informed about everything that is going to happen to them.

A pelvic exam just seem so benign to me. No pain, no lasting damage, really just sticking a light in and looking. Especially compared to leaving a permanent scar on someone with my first-ever stitching attempt, or the trauma of my first attempt to localize the radial artery with yet another shaking needle.

So I would love to obtain every patient's consent for every little thing we do to them in the name of learning. And I would love it if patients would offer up their bodies on the altar of our education. I would love it if they understood that they have found themselves in a teaching hospital and part of the game is to let blossoming little student doctors practice doctor things until one night (May 19th for me) they go to sleep caterpillars, melt into a little puddle of goo, and reemerge as full-fledged MD butterflies.

So this is a tough one for me.

What do you think?

Assorted anecdotes from surgery day 1

This entry brought to you courtesy of "the ex knife set."

No comments. Too tired to comment. Just stories.

First patient of the day. 64ish year old man, hospitalized for renal failure. During his hospital stay, the internal medicine staff began to suspect that he perhaps had some sort of psychiatric issues of an unspecified nature. They ordered a psych consult. Psychiatrist ruled that the patient posed no threat to himself or others and sent him back to the ward. A few hours later, he went missing from his bed. He was found shortly thereafter at the triage desk of the ER complaining of "chest pain." The cause of this chest pain?
A scalpel protruding from his right ventricle. Apparently he wandered into the hallway, grabbed the sharpest object he could find in the ward, and stuck it into his heart.

This prompted one of my favorite student-attending dialogues of all time:

Student: What is the prognosis after being stabbed in the right ventricle?
Doctor: About the same as being stabbed in the left ventricle.
::Walks away::

Patient two 30sish. Admitted due to multiple stab wounds to the . . . guess. .. yup! Right ventricle. The best part of his medical records: "Medical history significant for inspiring multiple homicide attempts." I did not realize until today that people wanting to kill you was a medical condition.

This was in fact, not the first time he had been stabbed in the heart. Handled it like a pro too. He was nearly discharged the day after surgery for stealing cigarettes from the nurses and smoking in his bed. With his oxygen connected and flowing.

The rest of the day was mostly spent taking out staples and sutures in the outpatient clinic. One of the good things about learning medicine in Israel is that there is much less bureaucracy surrounding what medical students can and cannot do. We've been sticking needles, fingers, and catheters in and taking blood, urine, and poo (<--technical medical term) out of patients since we first started on the wards. If the attending is comfortable with us and we're super confident we do just about any procedure we're moved to.

There's something amazing about the fact that the first time I take a scalpel or needle and thread to a person's skin will leave a mark that they'll carry around with them for the rest of their life.

That's inspiration to practice, I suppose. Off I go.



Tomorrow: A short news story and ramble on the ethics of medical education.

Typo of the day

I'm all out of love I'm soooooo looooost without yooouuuu

This post will work much better if you pick your favorite mid 80s lite rock song and sing it over and over in your head while you read.


Two days pre-pediatrics exam. I am sitting in my new favorite study haunt. An often-empty, well-lit cafe with decent to very good coffee depending on the day, the mood of the barrista, and the phase of the moon. They play the same 15 easy listening songs over and over again in a loop. This should bother me but I actually find it oddly comforting. I monitor my time by Take That, Sting, and Elton John. Second "I want you back," Coffee break! "Don't Let the Sun go Down on Me" means it's snack time. "Shape of my heart" generally signals a bathroom trip.



Ahhhh. . . Take that. ::sigh::

Studying pediatrics in a cafe offers a unique challenge. Namely, that much of my studying involves looking at pictures of rashes, birth defects, broken limbs, and genital malformations that I surmise most of this cafe's patrons would not be too delighted to accidentally catch glimpse of as they walk by my table.

I also tend to feel when I'm reading something naughty like I have a big cartoon thought bubble over my head and everyone around can tell I'm looking at something not fit for public consumption.

This results in me awkwardly arranging my book with my cell phone, sugar packets, and other books strategically covering the offending images. Which probably makes me look even more sketchy and just generally unusual.

The couple next to me today, however, erased any fears I may have had about inappropriate cafe behavior. They were in their mid 50s, on some kind of strange awkward adulterous vacation date. The woman was American, here visiting her daughter, the man Israeli. They were speaking English making it of course 100% impossible for me not to eavesdrop.

I suppose they figured that no one else in the cafe understood English because after 30 minutes or so of exchanging pleasantries and basic personal information, they launched into the most graphic, detailed discussion of their sexual likes and dislikes and lack of satisfaction in their marriages. And I mean graphic. And loud. Full voice, like they were talking about coffee or the weather. This included an enlightening 15 minute monologue from the woman about how comforting she finds it to perform oral sex (with vast amounts of detail on exactly how she enjoys performing it) and how disappointing it is that her husband doesn't like to receive.

And here I am carefully examining images of various infants' scrotums (scrota? scroti?) trying to identify the ones with hernias or fluid accumulation. It felt like this tremendously inappropriate moment.

And I'm trying so very hard to turn into a serious professional grown-up who doesn't giggle every time she opens a diaper and discovers that the newborn baby boy she's checking was literally "born ready".
Surprise!













In happy unrelated news- I present you with my favorite medically relevant cartoon of all time, courtesy of Nataliedee.com:


Happy bacteria!