My sister texted me to let me know I need to post. So here it is.
This morning (or the smorning for some of you) I woke up early and Matt drove me to school two hours before classes started. I was in green surgical scrubs that I had quite the adventure finding yesterday (as it turns out, you cannot buy surgical scrubs in the school book store) and it was about 25 degrees out. But all of that was ok, because I was observing in the OR for the first time!
Our patient was a 40-something father of two from Chicago. He has Loeys-Dietz Syndrome, a disease of the arteries and presenting with cleft palate, wide-spread eyes and skeletal deformities. Patients with Loeys-Dietz have a high risk of death from aortic aneurysm rupture. Our patient had had a previous major surgery to repair some blood vessels and today the patient had a valve-sparing aortic root replacement for an aortic root aneurysm. (Here's a link to a video of the surgery in someone else.) This basically means that the surgeons opened his chest, cut out part of the aorta coming out of his heart taking the blood to the rest of his body, and sewed in a tube-like graft. Unfortunately, I didn't get to see any of the procedure because I had to go to class... but I did have a fabulous first glimpse into the operating room and started learning about anesthesia.
Our patient, V, was visiting with his wife and college-age daughter when Dr. M., his anesthesiologist and I walked in. Dr. M. explained what her part in the procedure would be, what it would feel like to "fall asleep," how many tubes he would have coming out of his nose and mouth when he woke up in the Intensive Care Unit after the surgery, and that the "margaritas" she would give him through his IV would keep him very warm and feeling good throughout his recovery. V didn't have many questions, but his wife wondered if the surgeons were planning to look at his other large blood vessels while they had him opened? No, they weren't. That wasn't on the consent form. V's daughter asked if he would have chest tubes in after the surgery? No, not like last time. This time he would have similar tubes coming out of his lower abdomen though. I started to feel sweaty and weak. The combination of the excitement of wearing the green scrubs and blue meshy cap, the fact that we were talking to V and his family, and the fact that it was rather warm in the pre-op space didn't really work for me at that moment. I took a second to take a few deep breaths and realize that my only job was to watch. I wasn't in charge of anyone's life, I wasn't the one who had no control over his life.
V asked to speak with the chaplain right after his wife and daughter went to the waiting room. While we waited for the chaplain to arrive I sat down next to V and learned that he was from Chicago, his son was still home finishing up his last week of high school before the holidays and that their flight was delayed several times on the way to Baltimore on Sunday. His daughter is studying journalism and wants to get involved in sports reporting.
Dr. M. is such a wonderful teacher. She was teaching Dr. B., a 3rd year resident who physically did most of the work under Dr. M's guidance and direction. When they were putting V to sleep she told me everything they were doing and made sure I could see at all times. When you're knocked-out with anesthesia you can't breathe for yourself, so you must be intubated with a breathing tube. This breathing tube went down into V's trachea, through his vocal cords and was attached to a ventilator. While they were getting things set, Dr. M. had me squeezing on the blue air bag to ventilate V manually. Dr. M. explained that I was breathing for V, that it was a very necessary part of the procedure to put his to sleep and keep him asleep through the surgery. "And all before my first class."
I watched everyone start draping and scrubbing V's body to prep him for the surgery while Dr. M. and Dr. B. administered drugs, sucked air and fluid out of his stomach and placed a central like in the large artery under his clavicle. I did not touch anything blue. Blue things are sterile and I'm not allowed to touch anything blue. Other than the air bag, I didn't touch anything at all.
Although I didn't get to see V's surgery, I am comfortable with the amount I did get to see today and I'm eager to go back and learn more. Dr. M. emailed me to let me know that the surgery ended at 5pm and was not without complications. They actually had to reopen his chest to address some ventricular fibrillation, quivering of the heart muscle instead of solid contractions. I'm eager to hear how V did coming out of the anesthesia and how his recovery turns out, and I'm equally eager to sign up for more shadowing... now that I have this school thing under control!
Tuesday, December 14, 2010
Tuesday, November 23, 2010
Hypochondriasis
Also known as Medical Students' Disease. I'm pretty sure I caught it.
It's finally Thanksgiving Break! Unfortunately my sniffing and sneezing is getting in the way of my relaxation. The problem is that I'm terrified to take something that might help me sleep, like NyQuil. NyQuil contains pseudoephedrine that helps to relieve nasal congestion by shrinking swollen nasal mucous membranes. Today we learned that the pseudoephedrine also causes an increase in the secretion of a "natural drug" produced by the body called norepinephrine. Norepinephrine directly increases the heart rate and therefore increases blood pressure.
Flashback 12 hours: Lecture 2, Case 3: 45 year old female with history of depression comes in with a cold and cough. You, the doctor, tell her to go home and take over-the-counter cough medicine. She takes 2 tablespoons of NyQuil. Two hours later she experiences cardiac arrest.
So, the problem was unfortunately the doctor didn't ask about other medications the patient might have been taking. This woman was taking medication for depression (MAO Inhibitors) that prevent the breakdown of norepinephrine. So, one medication (NyQuil) increases the release of norepinephrine that directly increases the heart rate and the other drug (for depression) prevents the break down of this "natural drug," further increasing its effect on the heart. Result: cardiac arrest.
No, I'm not taking anti-depression drugs. But, maybe the Tylenol I took earlier (for which the mechanism of action in the body is still debated) or the Mucinex I just took (that is so potent that it should only be taken every 12 hours) has some component that will interact with a component of NyQuil and stop my heart, or neurons, or liver....
The simultaneously fascinating and extremely scary thing about being a med student is learning about these things you never really considered before. This also includes learning about how cancer develops (which I'm more than terrified about), or how many things have to go right in order to have a healthy, genetically normal and successfully delivered baby (without damage to the very fragile brachial plexus).
I hope this hypochondriasis is only temporary, but I have a feeling it might last for about 3.5 more years.
It's finally Thanksgiving Break! Unfortunately my sniffing and sneezing is getting in the way of my relaxation. The problem is that I'm terrified to take something that might help me sleep, like NyQuil. NyQuil contains pseudoephedrine that helps to relieve nasal congestion by shrinking swollen nasal mucous membranes. Today we learned that the pseudoephedrine also causes an increase in the secretion of a "natural drug" produced by the body called norepinephrine. Norepinephrine directly increases the heart rate and therefore increases blood pressure.
Flashback 12 hours: Lecture 2, Case 3: 45 year old female with history of depression comes in with a cold and cough. You, the doctor, tell her to go home and take over-the-counter cough medicine. She takes 2 tablespoons of NyQuil. Two hours later she experiences cardiac arrest.
So, the problem was unfortunately the doctor didn't ask about other medications the patient might have been taking. This woman was taking medication for depression (MAO Inhibitors) that prevent the breakdown of norepinephrine. So, one medication (NyQuil) increases the release of norepinephrine that directly increases the heart rate and the other drug (for depression) prevents the break down of this "natural drug," further increasing its effect on the heart. Result: cardiac arrest.
No, I'm not taking anti-depression drugs. But, maybe the Tylenol I took earlier (for which the mechanism of action in the body is still debated) or the Mucinex I just took (that is so potent that it should only be taken every 12 hours) has some component that will interact with a component of NyQuil and stop my heart, or neurons, or liver....
The simultaneously fascinating and extremely scary thing about being a med student is learning about these things you never really considered before. This also includes learning about how cancer develops (which I'm more than terrified about), or how many things have to go right in order to have a healthy, genetically normal and successfully delivered baby (without damage to the very fragile brachial plexus).
I hope this hypochondriasis is only temporary, but I have a feeling it might last for about 3.5 more years.
Monday, November 22, 2010
My theory on studying and food
During my freshmen year of college, I LOVED to snack on frosted raspberry poptarts while studying. I would use my Big Red Bucks and buy a package of 2 at the convenience store when leaving the all-you-can-eat dining hall and eat them for dessert while highlighting my textbooks. Ok fine, they were my second dessert, the soft serve ice cream bar was my first dessert at the end of my all-you-can-eat meal. Sidenote: When I came home for Thanksgiving during my freshmen year, my best friend's mom (really my "second mom" growing up) asked, "Are your wisdom teeth acting up again?" She was referring to the fact that about 15 months before I had my wisdom teeth out and subsequently got an infection causing my cheeks to balloon for days. "No. It's called the Freshmen 15."
So. That was the end of the raspberry poptarts. However, I still have a problem with snacking while studying! I cannot stop eating when my brain is working so hard! Therefore, my theory is: Studying really hard is very similar to running a marathon (like I would know.....), you use energy rapidly and get very hungry very quickly.
Last week: Me: "Matt, we have no more chex-mix." Matt: "REALLY? I just bought that bag!"
Two days later: Me: "We are out of rosemary and garlic triscuits." Matt: "I know. You ate ALL the snacks."
I don't actually know if using your brain burns calories, but I did a tiny bit of research and found this article which is slightly off topic, but interesting: "The energy expenditure of using a “walk-and-work” desk for office workers with obesity" by James Levine and Jennifer Miller out of the Mayo Clinic. Hm... what a workplace that would be.
What I would do
The "Audience response questions" did not work very well. No one responded! haha
Truthfully, it's not fair of me to ask people what they would have done... it's a hard topic and it would not have been anonymous. In class, we voted with clickers and there was no way to tell who said what. But I'll tell you how I voted, and then what actually happened in these two real cases.
In the case of the newborn Down syndrome whose parents refuse the life saving surgery, I would
b. Apply for court appointed guardianship so that an operation can be performed to save the child’s life.
I think this would cover the legal aspect of going against the wishes of the parents and give the child a chance at life. What actually happened was:
e. Leave the child at hospital B to die under the care of the house staff and nurses
It was explained that this was the decision of the medical team involved. They felt this was the most ethical choice. It makes me really sad.
In the case of the 25 year old severely burned in a motor vehicle accident and wanted his doctors and nurses to end his life, I would
d. Request psychiatric consultation to declare the patient incompetent to make decisions regarding his own care
... with the caveat that I wouldn't be pushing for the consultation to automatically declare the patient incompetent, rather be trying to determine if the patent was competent enough to make the decision to end his life. My feelings are that I would want to be able to make my own decisions about my life and care if ever in such a painful, devastating and unbearable situation. Therefore, this man should be allowed to make his own decisions if he was competent enough to do so.
What actually happened was the b. Consider the patient incapable of requesting withdrawal of care and continue regardless of patient wishes. The patient, Dax Cowart, is famous in the medical ethics world. Should the patient have the right to die? Dax subsequently went on to get married, go to law school and fight for the rights of patients to choose their fate.
Truthfully, it's not fair of me to ask people what they would have done... it's a hard topic and it would not have been anonymous. In class, we voted with clickers and there was no way to tell who said what. But I'll tell you how I voted, and then what actually happened in these two real cases.
In the case of the newborn Down syndrome whose parents refuse the life saving surgery, I would
b. Apply for court appointed guardianship so that an operation can be performed to save the child’s life.
I think this would cover the legal aspect of going against the wishes of the parents and give the child a chance at life. What actually happened was:
e. Leave the child at hospital B to die under the care of the house staff and nurses
It was explained that this was the decision of the medical team involved. They felt this was the most ethical choice. It makes me really sad.
In the case of the 25 year old severely burned in a motor vehicle accident and wanted his doctors and nurses to end his life, I would
d. Request psychiatric consultation to declare the patient incompetent to make decisions regarding his own care
... with the caveat that I wouldn't be pushing for the consultation to automatically declare the patient incompetent, rather be trying to determine if the patent was competent enough to make the decision to end his life. My feelings are that I would want to be able to make my own decisions about my life and care if ever in such a painful, devastating and unbearable situation. Therefore, this man should be allowed to make his own decisions if he was competent enough to do so.
What actually happened was the b. Consider the patient incapable of requesting withdrawal of care and continue regardless of patient wishes. The patient, Dax Cowart, is famous in the medical ethics world. Should the patient have the right to die? Dax subsequently went on to get married, go to law school and fight for the rights of patients to choose their fate.
Tuesday, November 16, 2010
What would you do?
From Dr. M's lecture today on Medical Ethics:
Case 1: Audience response question
Newborn with Trisomy 21(Down syndrome) transferred from hospital A to hospital B. Unable to keep food down, vomiting solid and liquid foods. Duodenal atresia (small intestine malformation), complete blockage beyond stomach. Surgical recommendation to relieve obstruction.
Parents refuse, citing:
• poor future quality of life for child
• additional drain on family’s resources away from other children
• the child is “as God made him” and it is God’s will that the child should be allowed to die on its own without intervention
What would you do?
a. Refuse to accept the parents wishes: repair the small intestine
b. Apply for court appointed guardianship so that an operation can be performed to save the child’s life.
c. Send the child to die at home with its parents
d. Transfer the child back to die in the initial hospital (hospital A)
e. Leave the child at hospital B to die under the care of the house staff and nurses
f. Administer lethal doses of medication to the child to end its life quickly as an alternative to starvation and dehydration.
Case 2: Audience response question
25 year old military pilot involved in motor vehicle accident with father, both engulfed by flames. His memory of scene of accident:
"I was burned so severely and in so much pain that I did not want to live even in the early moments following the explosion. A man who heard my shouts for help came running down the road, I asked him for a gun. He said, 'Why?' I said, 'Canʼt you see I am a dead man? I am going to die anyway. I have got to put myself out of this misery.' In a very kind and compassionate caring way, he said, 'I canʼt do that.”
Patientʼs father dies en route to hospital. Throughout his hospitalization and rehabilitation, he asks his doctors and nurses to end his life because he is in unbearable pain and knows that he is blind and deformed.
What would you do?
a. Respect the patient’s wishes and administer a lethal dose of morphine and barbiturates
b. Consider the patient incapable of requesting withdrawal of care and continue regardless of patient wishes
c. Consider the patient incapable of making informed decisions and defer to closest relative: his mother
d. Request psychiatric consultation to declare the patient incompetent to make decisions regarding his own care
e. Transfer the patient to another burn treatment facility
Please include your reasoning for your answer(s).
Case 1: Audience response question
Newborn with Trisomy 21(Down syndrome) transferred from hospital A to hospital B. Unable to keep food down, vomiting solid and liquid foods. Duodenal atresia (small intestine malformation), complete blockage beyond stomach. Surgical recommendation to relieve obstruction.
Parents refuse, citing:
• poor future quality of life for child
• additional drain on family’s resources away from other children
• the child is “as God made him” and it is God’s will that the child should be allowed to die on its own without intervention
What would you do?
a. Refuse to accept the parents wishes: repair the small intestine
b. Apply for court appointed guardianship so that an operation can be performed to save the child’s life.
c. Send the child to die at home with its parents
d. Transfer the child back to die in the initial hospital (hospital A)
e. Leave the child at hospital B to die under the care of the house staff and nurses
f. Administer lethal doses of medication to the child to end its life quickly as an alternative to starvation and dehydration.
Case 2: Audience response question
25 year old military pilot involved in motor vehicle accident with father, both engulfed by flames. His memory of scene of accident:
"I was burned so severely and in so much pain that I did not want to live even in the early moments following the explosion. A man who heard my shouts for help came running down the road, I asked him for a gun. He said, 'Why?' I said, 'Canʼt you see I am a dead man? I am going to die anyway. I have got to put myself out of this misery.' In a very kind and compassionate caring way, he said, 'I canʼt do that.”
Patientʼs father dies en route to hospital. Throughout his hospitalization and rehabilitation, he asks his doctors and nurses to end his life because he is in unbearable pain and knows that he is blind and deformed.
What would you do?
a. Respect the patient’s wishes and administer a lethal dose of morphine and barbiturates
b. Consider the patient incapable of requesting withdrawal of care and continue regardless of patient wishes
c. Consider the patient incapable of making informed decisions and defer to closest relative: his mother
d. Request psychiatric consultation to declare the patient incompetent to make decisions regarding his own care
e. Transfer the patient to another burn treatment facility
Please include your reasoning for your answer(s).
Thursday, November 11, 2010
It's Fall!
They told me these 4 years will fly by. I won't believe it when I'm finally graduating with my M.D. After only 3 months, I fully realize the truth in that statement. I can't believe we're already into November! I LOVE the fall! While growing up, the fall = a new school year. In Olean, NY September meant leaves changing colors, crisp breezes and back-to-school shopping at the Outlets or in Buffalo with my mom and sisters. (which begs the question: if I'm still starting a new school year in the fall, why no back-to-school shopping with my mom and sisters?!?!)
Anyway... here in Baltimore it doesn't seem like fall until well into November. So here we are! Finally. Last night, while studying for my metabolism exam (read: boring), I made (homemade!) hot chocolate, lit the Yankee candle that smells like apples and put on my favorite slippers. It was awesome!
Shout-Out to Kristen and Kathy for getting me addicted to the homemade hot chocolate they give out at Christmas:
Much of the reason my life is flying by can be attributed to the pace of the curriculum. Our "blocks" are 5-8 days long. Meaning a new topic, new teachers, new section leaders, and a new style every week or two. Today we had a metabolism exam (a block I wasn't particularly fond of, mostly due to the lack of organization of the faculty... how can posting powerpoint slides be that difficult!?), and tomorrow we start genetics. Then next Friday, a week from tomorrow, we have our genetics test. WOW.
In addition to that science-y curriculum, we are at the climax of our clinical skills curriculum. The day after my Thanksgiving Break I will perform a head-to-toe physical evaluation on a standardized patient. Get ready! To prepare for this we went to the hospital this past Monday to interview an inpatient and do an abbreviated physical exam. This patient has lupus, an autoimmune disease where the body attacks it's own cells and tissues. The patient had severe connective tissue disorders that caused hardening of the skin and bones and kidney failure among other things. He was so wonderful to interview. He was patient, kind, and understanding of our inexperience. When we asked him to let us know if he felt uncomfortable while we were examining him, his quote was, "You're probably more uncomfortable doing this than I am." Check.
Anyway... here in Baltimore it doesn't seem like fall until well into November. So here we are! Finally. Last night, while studying for my metabolism exam (read: boring), I made (homemade!) hot chocolate, lit the Yankee candle that smells like apples and put on my favorite slippers. It was awesome!
Shout-Out to Kristen and Kathy for getting me addicted to the homemade hot chocolate they give out at Christmas:
Homemade Hot Chocolate Mix
Ingredients:
1 large can of Nestle Quick Choc. Mix (32 oz?)
1/2 bag confectioners sugar
11 oz container of non-dairy coffee creamer
8-10 qt. box dry milk (Sanalac brand is best)
Combine all ingredients together in LARGE bowl. Blend well.
Much of the reason my life is flying by can be attributed to the pace of the curriculum. Our "blocks" are 5-8 days long. Meaning a new topic, new teachers, new section leaders, and a new style every week or two. Today we had a metabolism exam (a block I wasn't particularly fond of, mostly due to the lack of organization of the faculty... how can posting powerpoint slides be that difficult!?), and tomorrow we start genetics. Then next Friday, a week from tomorrow, we have our genetics test. WOW.
In addition to that science-y curriculum, we are at the climax of our clinical skills curriculum. The day after my Thanksgiving Break I will perform a head-to-toe physical evaluation on a standardized patient. Get ready! To prepare for this we went to the hospital this past Monday to interview an inpatient and do an abbreviated physical exam. This patient has lupus, an autoimmune disease where the body attacks it's own cells and tissues. The patient had severe connective tissue disorders that caused hardening of the skin and bones and kidney failure among other things. He was so wonderful to interview. He was patient, kind, and understanding of our inexperience. When we asked him to let us know if he felt uncomfortable while we were examining him, his quote was, "You're probably more uncomfortable doing this than I am." Check.
Wednesday, November 3, 2010
Dia de los Muertos
Today we finally honored the contributions of the donors that so selflessly gave their bodies. Some of my classmates put together a wonderful celebration that allowed us to reflect on death, healing and learning. A few people read poems, there was a violin performance, and two of my classmates sang The Only Exception by Paramore. I was truly touched by the offers of others, and finally had the opportunity and venue to say "Thank you" to the person I got to know so well. A moment of silence gave us the opportunity to write down a reflection and drop it in a bowl of water on a Dia de los Muertos altar.Thank you for being the most amazing teacher, for letting me discover the details, and for giving me a completely new appreciation for life and the role of a physician.
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