Another rotation over and done with. It was a good one that I learned a lot from. As I've said before, the Docs at Cardiovascular Consultants are top notch.
The last week in the office was a lot more of the same except for one CABG I got to see at T-Bird. The patient was a 41 yo with CAD due to radiation therapy 10 years earlier for a large lymphoma. He had no other risk factors and no pertinent family history. I assumed that this would make the surgery and recovery easier for him. Only afterwards did I learn how wrong that idea is.
Opening the chest and harvesting the saphenous vein went well. The first graft even went pretty good with a not abnormally large drop in BP when the coronary artery was tied off before sewing in the graft. However, the second graft didn't go so smoothly. The surgeon kept talking with the anesthesiologist about BP, but as the second vessel was tied off the BP dropped over 30 seconds from about 110 systolic to under 30!! The surgeon started yelling and cussing, especially towards the anesthesiologist. As the nurses frantically rushed to set up the bypass machine and one prepped the defib paddles, the surgeon manually pumped the heart. The pumping kept the blood moving which finally enabled the anesthesiologist's meds (epi) to get back to the heart.
The BP finally returned and the surgeon apologized but asked me to move to the other end of the table so that the anesthesiologist wasn't distracted. The two docs explained that the problem wasn't really communication though. Younger CAD patients don't have time to build up collateral blood flow in the heart. So this BP drop is rare. The other interesting part of this surgery was that we found an additional (reminant) lymphoma on the left side of the chest above the heart. The surgeon wasn't able to remove because the phrenic nerve passed right through it. I don't think the patient wouldn't have appreciated a life with half his diaphragm paralyzed.
The rest of my time in the office was spent seeing spent, reading up on Cardio and watching a few stress tests with nuclear scans. The office staff was great and I got along great with the patients. But I missed not seeing any kids or healthy people.
Instead of continuing the previous week's great work-put regimen, I got very little sleep and couldn't stop thinking about residencies. I was up until 2am every night researching programs around the country, looking at other specialties and reading discussion threads on StudentDoctor.net. While the money in other specialties like Cardio is appealing, I'm even more convinced that Family Medicine is the right place for me. There's a few programs in the Northwest and Phoenix that look good, but the Midwest programs have the best pay and benefits. However, a few Colorado programs have a pretty unbeatable combination of teaching and lifestyle.
I have my list of program attributes and tons of book-marked sites. Becky is teasing to get going on my spreadsheets. And even bumped in Tucker this morning at the campus cafeteria and we ended up discussing our last rotations and residency searches for a couple hours. Seeing him and comparing notes was a great excuse to put off studying for my Cardio shelf test on Tuesday. If I had to choose today, I think Scottsdale Healthcare would be my first choice with a couple Colorado programs coming close behind. Becky and I are going to John C. Lincoln's residency program Open House this week, so that provide some additional insight on local programs and my decision process.
Lastly, I managed to return a few things last night and purchase a couple dress shirts and ties at Fashion Square (the only Nordstrom's in all of Phoenix!). It was more than I wanted to spend, but now I have several more interchangeable outfits for the clinics that look good with or without a tie.
Saturday, October 21, 2006
Tuesday, October 10, 2006
Interesting weekend...
Saturday I finally got in some decent study hours. I went back to campus and owned a familiar study table in the cafeteria (my old study lounge one was take!). I took a break to see the boys' soccer game and get some lunch, but it felt good to cover some testable Cardiology material.
On the way home I picked up some pizza for the family and while waiting for it get cooked I decided to peek at the latest in bikes at the nearby cycle store. Well, I found a full carbon bike for $995! And it was a pretty nice one with Ultegra and 105 components, good geometry and a perfect fit for me. Well, I had been planning a getting a really nice bike for graduation, but why lose 18 months of incredible Phoenix biking weather? It was the last of 40 or so bikes at this price among four stores and while I was looking at it we got a call that someone at another store wanted it.
I had them hold it and went to talk to Becky and talk it over. Well, we decided that a little more debt wasn't going to break the bank (thank goodness for home appreciation) and the bike would a long overdue 40th B-day present for me. I also planned to get Becky some diamond earrings for her B-day on the 11th. We also decided to look into refinancing the home to pay for some long overdue improvements (fence, A/C, carpets, garage storage). I stayed up way too late looking at bike reviews, comparisons and deals on the Internet (Ebay, Craigslist, etc.) to make sure it was a good deal, and except for the wheels, which I'll have to replace soon, it was a great deal.
Sunday we cleaned house and did some chores. I picked up my new carbon bike at 11am after a thorough test ride and then patiently went grocery shopping with Becky. As soon as I got home I rode around the block with boys and then went a nice 20 miler or so that felt terrific. I can't wait to ride with folks from school or other locals now. Sunday night I did some more diamond shopping for Becky, but not before hearing that Julie is quitting her nanny job.
Becky's sister Julie has helped watch the kids for about two years now. But she wants to start her own career in Seattle and the boys are just about old enough to watch themselves for an hour here or there. It was coming, but the timing is more than a bit strange. So while I was bidding on Ebay today Becky was lining up childcare and school transportation in case Julie leaves soon.
Today was fine in the cardiology office. Not as exciting as the hospital, but I'm sure there's a lot learn in outpatient to. I went for a swim this evening and have spent the couple hours trying to finally finish the Gamma Knife paper I've been working on forever. The guilt was nagging at me for not completing it, plus Becky's mom has decided to stay with us for two weeks so I lose my office tomorrow!
We knew her brothers were coming for Becky's 40th, but Marge was a surprise. We are both pretty sure it's more to support Julie than to experience Becky's 40th. As usual I had no say in the matter, but now have to figure out how to function for the next two weeks of chaos.
On the way home I picked up some pizza for the family and while waiting for it get cooked I decided to peek at the latest in bikes at the nearby cycle store. Well, I found a full carbon bike for $995! And it was a pretty nice one with Ultegra and 105 components, good geometry and a perfect fit for me. Well, I had been planning a getting a really nice bike for graduation, but why lose 18 months of incredible Phoenix biking weather? It was the last of 40 or so bikes at this price among four stores and while I was looking at it we got a call that someone at another store wanted it.
I had them hold it and went to talk to Becky and talk it over. Well, we decided that a little more debt wasn't going to break the bank (thank goodness for home appreciation) and the bike would a long overdue 40th B-day present for me. I also planned to get Becky some diamond earrings for her B-day on the 11th. We also decided to look into refinancing the home to pay for some long overdue improvements (fence, A/C, carpets, garage storage). I stayed up way too late looking at bike reviews, comparisons and deals on the Internet (Ebay, Craigslist, etc.) to make sure it was a good deal, and except for the wheels, which I'll have to replace soon, it was a great deal.
Sunday we cleaned house and did some chores. I picked up my new carbon bike at 11am after a thorough test ride and then patiently went grocery shopping with Becky. As soon as I got home I rode around the block with boys and then went a nice 20 miler or so that felt terrific. I can't wait to ride with folks from school or other locals now. Sunday night I did some more diamond shopping for Becky, but not before hearing that Julie is quitting her nanny job.
Becky's sister Julie has helped watch the kids for about two years now. But she wants to start her own career in Seattle and the boys are just about old enough to watch themselves for an hour here or there. It was coming, but the timing is more than a bit strange. So while I was bidding on Ebay today Becky was lining up childcare and school transportation in case Julie leaves soon.
Today was fine in the cardiology office. Not as exciting as the hospital, but I'm sure there's a lot learn in outpatient to. I went for a swim this evening and have spent the couple hours trying to finally finish the Gamma Knife paper I've been working on forever. The guilt was nagging at me for not completing it, plus Becky's mom has decided to stay with us for two weeks so I lose my office tomorrow!
We knew her brothers were coming for Becky's 40th, but Marge was a surprise. We are both pretty sure it's more to support Julie than to experience Becky's 40th. As usual I had no say in the matter, but now have to figure out how to function for the next two weeks of chaos.
Saturday, October 07, 2006
Cardio Inpatient Done
The last two weeks have been much better than I expected. I am really enjoying the group I'm working with, Cardiovascular Consultants (CVC). And my "team" of preceptors are just outstanding. They have my admiration as professionals and teachers.
It's not that I've been sold on Cardiology myself, but I certainly appreciate what the Docs offer and what they do to earn a VERY nice living. They all spent seven to eight years in residency AFTER medical school. But in a pinch they can: handle a patient's overall medical needs; diagnose life threatening conditions invasively and non-invasively; and FIX many patients' heart short of an open-heart CABG surgery. It's not a bad job for those dedicated enough to get the training.
I haven't finished my logs, but in the past two weeks I've seen about thirty patients on my own. Half were new patients requiring H&Ps and half existing patients requiring Progress Notes. I reviewed the patients charts, questioned (the ones that could talk) and examined them, wrote up the notes and put them into the charts. That was most of my mornings.
Afternoons consisted of watching lots of procedures and revisiting patients and their charts with the cardiologists. The latter is where my education really took place. I learned the questions and examination tests I forgot. I received feedback on my notes, especially the Assessment and Plan sections where I'm still very uneducated. Some of my most noteworthy patients included:
1) Young mother of two who had her first pacemaker at 8 yrs old (congenital heart block) and needs a) leads from her first of three, non-functional pacer removed and b) a new Bi-ventricular pacer with ICD (defibrillation) capability installed.
2) A young man with Osteogenesis Imperfecta (blue sclera and lots of broken bones!) that had a frustratingly intermittent A-fib interfering with his job and lifestyle. Our EP (electrophysiologist) manipulated his heart very aggressively with drugs and four intravenous catheters but we still couldn't find any structural abnormalities.
3) A middle-aged female diabetic and smoker that had two CABGs (six vessels total) and an angioplasty (two stents).
4) Several older post-AMI patients with poor cardiac output (low EF) who needed complicated drug regimens complicated by conditions like ARF (acute renal failure), COPD and PVD (peripheral vascular disease). I learned what rhythm vs. rate control really means and its implications.
The procedures I got to see up close and personal included right and left heart catheterization, angioplasty, electrophysiology, defibrillation/conversion, stress testing, angiograms and echocardiology. The stress testing is noteworthy because if I do end up going rural Family that is something I will probably do in the office before sending patients to the "big city" cardiologist.
The procedures I would have liked to see include open heart CABG, stenting an AMI, balloon valvuloplasty and closure of intracardiac shunts like patent VSDs. Patti, the awesome NP I worked with a lot, is going to call me if one of our patients goes in for a CABG, so I still have a good shot to run across the street in the next two weeks and see one of those.
I even managed to maintain a life and get in some swimming. I just ordered an indoor trainer so I can watch Board review lectures while stationary biking a couple mornings a week. But that did get me a little envious of a couple of the cardiologists. Between patients they planned trips to Hawaii and Switzerland, traded notes on their Computrainer stationary bike sessions (on custom Trek Madones of course), discussed upcoming triathlons and offered advice on expensive cars, food, wine, etc. They definately live in a different socio-economic spot than I've been around.
My fear now is the next two weeks of outpatient cardiolgy in the office are going to be boring. I just hope that I can continue to improve on my charting and examination skills by seeing patients on my own followed by review and feedback.
It's not that I've been sold on Cardiology myself, but I certainly appreciate what the Docs offer and what they do to earn a VERY nice living. They all spent seven to eight years in residency AFTER medical school. But in a pinch they can: handle a patient's overall medical needs; diagnose life threatening conditions invasively and non-invasively; and FIX many patients' heart short of an open-heart CABG surgery. It's not a bad job for those dedicated enough to get the training.
I haven't finished my logs, but in the past two weeks I've seen about thirty patients on my own. Half were new patients requiring H&Ps and half existing patients requiring Progress Notes. I reviewed the patients charts, questioned (the ones that could talk) and examined them, wrote up the notes and put them into the charts. That was most of my mornings.
Afternoons consisted of watching lots of procedures and revisiting patients and their charts with the cardiologists. The latter is where my education really took place. I learned the questions and examination tests I forgot. I received feedback on my notes, especially the Assessment and Plan sections where I'm still very uneducated. Some of my most noteworthy patients included:
1) Young mother of two who had her first pacemaker at 8 yrs old (congenital heart block) and needs a) leads from her first of three, non-functional pacer removed and b) a new Bi-ventricular pacer with ICD (defibrillation) capability installed.
2) A young man with Osteogenesis Imperfecta (blue sclera and lots of broken bones!) that had a frustratingly intermittent A-fib interfering with his job and lifestyle. Our EP (electrophysiologist) manipulated his heart very aggressively with drugs and four intravenous catheters but we still couldn't find any structural abnormalities.
3) A middle-aged female diabetic and smoker that had two CABGs (six vessels total) and an angioplasty (two stents).
4) Several older post-AMI patients with poor cardiac output (low EF) who needed complicated drug regimens complicated by conditions like ARF (acute renal failure), COPD and PVD (peripheral vascular disease). I learned what rhythm vs. rate control really means and its implications.
The procedures I got to see up close and personal included right and left heart catheterization, angioplasty, electrophysiology, defibrillation/conversion, stress testing, angiograms and echocardiology. The stress testing is noteworthy because if I do end up going rural Family that is something I will probably do in the office before sending patients to the "big city" cardiologist.
The procedures I would have liked to see include open heart CABG, stenting an AMI, balloon valvuloplasty and closure of intracardiac shunts like patent VSDs. Patti, the awesome NP I worked with a lot, is going to call me if one of our patients goes in for a CABG, so I still have a good shot to run across the street in the next two weeks and see one of those.
I even managed to maintain a life and get in some swimming. I just ordered an indoor trainer so I can watch Board review lectures while stationary biking a couple mornings a week. But that did get me a little envious of a couple of the cardiologists. Between patients they planned trips to Hawaii and Switzerland, traded notes on their Computrainer stationary bike sessions (on custom Trek Madones of course), discussed upcoming triathlons and offered advice on expensive cars, food, wine, etc. They definately live in a different socio-economic spot than I've been around.
My fear now is the next two weeks of outpatient cardiolgy in the office are going to be boring. I just hope that I can continue to improve on my charting and examination skills by seeing patients on my own followed by review and feedback.
Sunday, October 01, 2006
Cardio Week One
The hospital isn't as addictive and cardiology isn't as specialized as I presumed. The hospital has it benefits, like lots of resources, but it is a large complex organism with some parts dysfunctional at any given time. And you rarely have any control over those parts.
Cardiology seems more like primary care for large percentage of the geriatric population with cardio problems. Internal medicine rounds our patients and QB's the other specialties, but it sure seems like we run the show on the majority of cases.
I'm still way too slow on H&Ps, but doing well as usual with the patients. My studying is better than previous rotations but still has room to improve. It's difficult this weekend because I'm at home watching the boys while Becky and her sister are in Spokane for their grandmother's 90 B-day.
The boys had a sleep-over Friday with a couple friends and secretly stayed up until about 3am. That made for a great Saturday morning and soccer game. Picking up their friends was kinda fun though because we "magic schoolbus" night at the boys' school. Connor's M&M model of planet earth was a big hit. I got to meet Colton's new buddy and his parents. We even discussed get togethers for them finally. We also cleared up some of the drama with Colton and Becca's long-term "relationship". They never even held hands, but "dated" for almost two years :-). Colton wasn't very nice with the break-up so Colton got some early lessons in polite social behavior and friendship.
He actually used a line from "50 ways to break up with your lover" on Becca and then ran away so Jacob could interrupt; "you're dumped!" Even in 3rd grade, the kids need to be nicer. Just as importantly many of us parents discussed where the 6th graders are going next year. Challenge Charter is only K-6 and deadlines for many of the best Junoir Highs are in December.
This morning the boys have in much better moods. We chores done relatively quickly and now I'm procrastinating from putting together (I hope) the final draft on my Gamma Knife paper for Matt. If Gigi got me the correct graphs and stats, I should be able to just plug them in. It will be so nice to get that off my table.
Parting thoughts on Cardiology. I like the Docs and job is pretty cool. But they do work hard and average about 8 years of residency. The payoff just isn't there for me. But I this is very good rotation and I'm going to learn a ton. I can't wait to see my first CABG operation.
Cardiology seems more like primary care for large percentage of the geriatric population with cardio problems. Internal medicine rounds our patients and QB's the other specialties, but it sure seems like we run the show on the majority of cases.
I'm still way too slow on H&Ps, but doing well as usual with the patients. My studying is better than previous rotations but still has room to improve. It's difficult this weekend because I'm at home watching the boys while Becky and her sister are in Spokane for their grandmother's 90 B-day.
The boys had a sleep-over Friday with a couple friends and secretly stayed up until about 3am. That made for a great Saturday morning and soccer game. Picking up their friends was kinda fun though because we "magic schoolbus" night at the boys' school. Connor's M&M model of planet earth was a big hit. I got to meet Colton's new buddy and his parents. We even discussed get togethers for them finally. We also cleared up some of the drama with Colton and Becca's long-term "relationship". They never even held hands, but "dated" for almost two years :-). Colton wasn't very nice with the break-up so Colton got some early lessons in polite social behavior and friendship.
He actually used a line from "50 ways to break up with your lover" on Becca and then ran away so Jacob could interrupt; "you're dumped!" Even in 3rd grade, the kids need to be nicer. Just as importantly many of us parents discussed where the 6th graders are going next year. Challenge Charter is only K-6 and deadlines for many of the best Junoir Highs are in December.
This morning the boys have in much better moods. We chores done relatively quickly and now I'm procrastinating from putting together (I hope) the final draft on my Gamma Knife paper for Matt. If Gigi got me the correct graphs and stats, I should be able to just plug them in. It will be so nice to get that off my table.
Parting thoughts on Cardiology. I like the Docs and job is pretty cool. But they do work hard and average about 8 years of residency. The payoff just isn't there for me. But I this is very good rotation and I'm going to learn a ton. I can't wait to see my first CABG operation.
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