The trip home wasn't too eventful. I gained even more appreciation for the book Surgical Recall, a pocket-sized 700-page book in Q&A style that really covers a lot of basic surgery territory. Even with all the hours in the air I've only read about 200 pages, but hopefully I'll get more read in the next few weeks.
It was sure nice to get home and see the family. We just hung out and didn't worry too much about chores, homework (mine or the kids) or packing. Got caught up on Gray's Anatomy and I hope the weird afterlife scenes are over.
So now it's Sunday and I have to start on the To Do list: new tires, wash, packing and all the post rotation logs and evals. I've had enough time to think back on the last month now that I sum up the experience as a good rotation, where I learned a lot (got my tuition's worth) but one I probably could have done equally well closer to home. I'm still miffed about my Maricopa paperwork mix-up that resulted in my losing that rotation. However, that whole situation is what allowed to have the excellent Peds ER rotation. I'm not sure I would be looking so closely at EM if had gone as planned.
The surgery rotation ended with a few good surgeries, more office hours and a couple in office I&D type procedures. The Attendings and Resident were very complementary in their feedback and interested in our feedback. I'm fairly confident of getting a decent evaluation.
Tomorrow is day one on a new job again. I drive to Show Low (on new tires I hope) at 6am for rural surgery. We see how well the last month prepared me to step in and really start participating in surgeries. Every indication I gotten from the three surgeons I'll be working with is that I should be able to do a lot more than just cut sutures, staple and steri-strip.
Saturday, February 24, 2007
Sunday, February 18, 2007
One week left in Toledo
Last week was even more routine than week two. We had some interesting surgeries that I mentioned a couple posts ago, but nothing too unusual. I'm getting pretty familiar with the typical general surgical procedures like gallbladder removal, inguinal and abdominal wall hernia repair and appendectomies. I also got to first assist on a Lap Chole which was a nice change from holding the camera. I hope that next month, my rural surgery rotation will be more varied and allow me to first assist more.
The lady with the necrotizing fasciitis was scheduled to go to surgery for another debridement. I wanted to watch the surgery on Friday, but had to head to one of the other hospitals. It will be interesting to see how she's fairing tomorrow, Monday. I think I've mentioned Streptococcus Decapitii to half the students on the Wards.
Now it's time to catch up on some reading and get my LOR stuff ready to send out.
The lady with the necrotizing fasciitis was scheduled to go to surgery for another debridement. I wanted to watch the surgery on Friday, but had to head to one of the other hospitals. It will be interesting to see how she's fairing tomorrow, Monday. I think I've mentioned Streptococcus Decapitii to half the students on the Wards.
Now it's time to catch up on some reading and get my LOR stuff ready to send out.
Match is one year away!
It was an exciting week for the MSIVs. The Osteopaths got the results of their Match and the Allopaths had to submit their Match lists. The latter's results won't be out until the middle of March. I wonder how many AZCOM MSIVs were scrambling for Residencies on campus this last week?
All this talk of Residency has made me reflect on FP pretty hard. So be forewarned, this post is more about another week of soul searching than medicine.
I believe I would be good at rural FP and the job would be thoroughly satisfying. My lingering doubts are around whether the family would like living in a rural town and being stuck there once we establish ourselves. Becky won't have many careers options other than helping to run my practice. Maybe she find a foundation to run or get elected to something, but not much need for a CFO.
At this is my justification for not reading much the last two days. I've spending most of my time researching Emergency Medicine, Anesthesia and Surgery residencies to see what options are out there and how they "feel" as I try to envision those specialties as careers. Yes, I've made a couple of spreadsheets.
The timing is getting pretty important now because there's still a possibility of changing of my last rotation this year. I also need to start applying for audition rotations the beginning of my fourth year in order to reserve openings. I may just start and double book myself to be prepared.
EM is nice in that you work reasonable hours. Typical schedules include 4 x 12 hrs for three weeks then the fourth week off, or 7 x 12 hours every other week. Those hours are usually very busy and can be quite stressful. But when you're off, you're off (no call). You make more than FP and do lots of procedures. You make good money from day one and can readily move to a different hospital with no drop in income. The down-sides are screwing with your circadian rhythms (night shifts), no continuity of care (triage-stabilize-move on) and always working in an ER environment.
Anesthesiologists work longer hours, have an additional year of residency and have job that can be very boring (punctuated by moments of terror). They do a fair amount of procedures, have some patient interaction and make a very nice living.
Both of these have one big negative I just discovered. The residency options aren't very good. EM has few Western US programs, but tons of DO programs in the Midwest. Anesthesia just has programs spread out everywhere. Both are fairly competitive, but the latter even more so. We would probably have to be willing to move where ever I got accepted. With FP I feel pretty confident I can pick three top programs in nice places to live and get one for sure.
Surgery worries me because residency and practice hours suck. You have to love the ER because it's your mistress. And there's my age factor. I know surgeons that operate into their 70's but that is the exception. That's why rural FP is so appealing. You can do minor surgeries (still great fun!) but they don't dictate your lifestyle and you can stop whenever you choose.
Becky is also doing a bit of soul searching herself while spending the weekend with the kids at my Dad's place in SD. Maybe he'll have some words of wisdom for her. Her careers desires may very well be the deciding factor on my specialty.
My uncle form Ann Arbor is on his way down to pick me up. I've never seen his place. It will be nice to get away for a few hours and talk this out myself. His daughter, my cousin, just started medical school at U. of Washington so he may have more interest seeing as how his daughter will be going through this in a couple of years.
All this talk of Residency has made me reflect on FP pretty hard. So be forewarned, this post is more about another week of soul searching than medicine.
I believe I would be good at rural FP and the job would be thoroughly satisfying. My lingering doubts are around whether the family would like living in a rural town and being stuck there once we establish ourselves. Becky won't have many careers options other than helping to run my practice. Maybe she find a foundation to run or get elected to something, but not much need for a CFO.
At this is my justification for not reading much the last two days. I've spending most of my time researching Emergency Medicine, Anesthesia and Surgery residencies to see what options are out there and how they "feel" as I try to envision those specialties as careers. Yes, I've made a couple of spreadsheets.
The timing is getting pretty important now because there's still a possibility of changing of my last rotation this year. I also need to start applying for audition rotations the beginning of my fourth year in order to reserve openings. I may just start and double book myself to be prepared.
EM is nice in that you work reasonable hours. Typical schedules include 4 x 12 hrs for three weeks then the fourth week off, or 7 x 12 hours every other week. Those hours are usually very busy and can be quite stressful. But when you're off, you're off (no call). You make more than FP and do lots of procedures. You make good money from day one and can readily move to a different hospital with no drop in income. The down-sides are screwing with your circadian rhythms (night shifts), no continuity of care (triage-stabilize-move on) and always working in an ER environment.
Anesthesiologists work longer hours, have an additional year of residency and have job that can be very boring (punctuated by moments of terror). They do a fair amount of procedures, have some patient interaction and make a very nice living.
Both of these have one big negative I just discovered. The residency options aren't very good. EM has few Western US programs, but tons of DO programs in the Midwest. Anesthesia just has programs spread out everywhere. Both are fairly competitive, but the latter even more so. We would probably have to be willing to move where ever I got accepted. With FP I feel pretty confident I can pick three top programs in nice places to live and get one for sure.
Surgery worries me because residency and practice hours suck. You have to love the ER because it's your mistress. And there's my age factor. I know surgeons that operate into their 70's but that is the exception. That's why rural FP is so appealing. You can do minor surgeries (still great fun!) but they don't dictate your lifestyle and you can stop whenever you choose.
Becky is also doing a bit of soul searching herself while spending the weekend with the kids at my Dad's place in SD. Maybe he'll have some words of wisdom for her. Her careers desires may very well be the deciding factor on my specialty.
My uncle form Ann Arbor is on his way down to pick me up. I've never seen his place. It will be nice to get away for a few hours and talk this out myself. His daughter, my cousin, just started medical school at U. of Washington so he may have more interest seeing as how his daughter will be going through this in a couple of years.
Wednesday, February 14, 2007
Snowed In
We had at least eight inches fall last night. This morning they called it a Level III emergency so non-Healthcare folks could be ticketed for driving on the roads. The schools have been out all week. Some of the drifts this morning were waist high.
Our Chief made it in late, but Jason didn't, so the two of us did rounds at a fairly lazy pace. The morning procedures had been canceled. And while in the ICU visiting my favorite patient at the moment (a repeat ventral hernia repair) we came across a pretty fascinating ID case.
A 41 year old woman came down with Strep throat along with two family members. However, her infection progressed to necrotizing fasciitis. I couldn't see much since her neck was completely covered with dressings and a trach tube, but the nurse said ENT has had to debride her neck twice. She's almost been decapitated by Strep throat!! Obviously she has to have some co-morbidity like Diabetes or an immune-compromised condition. The infection is still spreading down her trunk, so it doesn't look like any antibiotics can save her at this point.
Even if she did survive, they had to remove all her neck muscles, so her trachea and jugulars are exposed. She'd never be able to move head on her own again. The whole thing is morbidly fascinating.
I didn't feel well around lunch, so I let Jason, the third student and our Chief John head over to the hospital where one of our Attnedings did an inguinal hernia, a Lap Chole and a Lap Chole that had to be converted to an open surgery. Attendings have only so much patience for removing big gallstones stuck in ducts with laprascopic tools before cutting the patient open. I missed some good scrub time, but I feel better after a long nap. And Jason just got home so it was a long afternoon in scrubs.
Tomorrow is Thursday, we have our half day a week of didactics starting at 7am. That means fast rounds starting at 6am. Hopefully I can peak in on the woman with no neck to see how she's doing - and maybe answer the question how this unheard of complication could have happened.
Our Chief made it in late, but Jason didn't, so the two of us did rounds at a fairly lazy pace. The morning procedures had been canceled. And while in the ICU visiting my favorite patient at the moment (a repeat ventral hernia repair) we came across a pretty fascinating ID case.
A 41 year old woman came down with Strep throat along with two family members. However, her infection progressed to necrotizing fasciitis. I couldn't see much since her neck was completely covered with dressings and a trach tube, but the nurse said ENT has had to debride her neck twice. She's almost been decapitated by Strep throat!! Obviously she has to have some co-morbidity like Diabetes or an immune-compromised condition. The infection is still spreading down her trunk, so it doesn't look like any antibiotics can save her at this point.
Even if she did survive, they had to remove all her neck muscles, so her trachea and jugulars are exposed. She'd never be able to move head on her own again. The whole thing is morbidly fascinating.
I didn't feel well around lunch, so I let Jason, the third student and our Chief John head over to the hospital where one of our Attnedings did an inguinal hernia, a Lap Chole and a Lap Chole that had to be converted to an open surgery. Attendings have only so much patience for removing big gallstones stuck in ducts with laprascopic tools before cutting the patient open. I missed some good scrub time, but I feel better after a long nap. And Jason just got home so it was a long afternoon in scrubs.
Tomorrow is Thursday, we have our half day a week of didactics starting at 7am. That means fast rounds starting at 6am. Hopefully I can peak in on the woman with no neck to see how she's doing - and maybe answer the question how this unheard of complication could have happened.
Monday, February 12, 2007
Interesting day...
I started a little late, 6:30am for rounds instead of 6:00am. Got done by our 8:30am, but it ended up being a hernia repair instead of a planned colonoscopy. We repaired the guy's hernia last week. It was a huge one he had had for years with pretty much all of his bowels in front of the remains of his abdominal wall. He had lived a hard 61 years.
Well, we had hernia repair wound dehiscence. So our surgical Attending started the week in a foul mood. At least he doesn't take his anger out on personally. Still, everyone tends to tiptoe around the OR on days like this. The patient's tissue was so bad that he tore the sutures holding the mesh down. He had an elastic binder and staples holding his guts inside, so we had to rush him to surgery before they spilled onto his bed!
The surgery was very extensive. We put down two layers of mesh this time, and huge pieces sutured almost to his sides. If they tear out this time, he may have to live with the result because there won't be enough good fascia left to suture.
Then we had a radioactive labeled sentinel biopsy and mastectomy. It was another hard life case. She had a tumor as hard a rock encompassing most of her breast. It must have been palpable for years. The lymph nodes came back metastatic. So in addition to losing her breast, she's going to get at least radiation treatment. That's best case, if we don't find any metastasis.
Then Jason and I grabbed a quick dinner and saw a new consult in the ER (inguinal and scrotal abscesses) before rounding on our patients with our Attending. It was pretty quick, but we didn't get done until 7pm so it was a long day.
Now it's time to start studying!
Well, we had hernia repair wound dehiscence. So our surgical Attending started the week in a foul mood. At least he doesn't take his anger out on personally. Still, everyone tends to tiptoe around the OR on days like this. The patient's tissue was so bad that he tore the sutures holding the mesh down. He had an elastic binder and staples holding his guts inside, so we had to rush him to surgery before they spilled onto his bed!
The surgery was very extensive. We put down two layers of mesh this time, and huge pieces sutured almost to his sides. If they tear out this time, he may have to live with the result because there won't be enough good fascia left to suture.
Then we had a radioactive labeled sentinel biopsy and mastectomy. It was another hard life case. She had a tumor as hard a rock encompassing most of her breast. It must have been palpable for years. The lymph nodes came back metastatic. So in addition to losing her breast, she's going to get at least radiation treatment. That's best case, if we don't find any metastasis.
Then Jason and I grabbed a quick dinner and saw a new consult in the ER (inguinal and scrotal abscesses) before rounding on our patients with our Attending. It was pretty quick, but we didn't get done until 7pm so it was a long day.
Now it's time to start studying!
Sunday, February 11, 2007
Second week on surgery
Another week of fun surgeries such as bowel resections, big hernia repairs and breast lumpectomies. It definitely felt more routine, even though the learning curve is still quite steep. I wasn't allowed to much more in the OR, but got scrubbed in on most of the good cases and did a decent job holding retractors, guiding cameras and closing up with sutures and staples. It's getting easier to anticipate the surgeons needs and they aren't jumping on us as much for not catching on to their intentions.
Rounding is getting easier. I'm getting more efficient at the brief physical exam and progress note. I still miss knowing the whole picture on patients, but I only have time to check on GI and surgery-related issues. Plus, there's usually other specialists or primary care docs on board to address everything else.
Our third student is a decent guy, but I sure started the week miffed about giving up a third of the cases. We'll see how this works out, but so far I only feel like he's taken some office visits - which is just fine.
Our intern and Chief resident (since he's the only resident in this new program) went away for the weekend so I house sat for him. It was a wonderful break from the "cell". I played with his boxer Griffin, got to use his Saab and slept on a real bed. Of course I stayed up too late on Friday enjoying cable TV again.
Rounding this weekend with our Surgeon on call as rewarding. Jason and I scrubbed in on a morning X lap (exploratory bowel surg) since the Chief was gone. We also had the opportunity to share everything we'd been assigned to read. Both of did very well according the surgeon and scrub tech. Jason didn't feel great, so he went home early. This gave me a lot of face time with my Attending. She spent a lot of time teaching and explaining things. It was SO much different than the classic arrogant surgeon-student relationship or the Medicine Attendings with God complexes I met at the VA. Now I have to read up on C. difficile and breast pathology.
One case is worth highlighting because it's so disturbing. We have a women who is an illegal alien getting an incredible amount of taxpayer funded care for no good reason other than her family isn't ready to let her go. The woman is a vegatable from a CVA, has a trach, and can't speak English anyway. Moreover, her kidneys, heart, liver and circulatory systems are collapsing. Finally she has ALL the superbugs: VRE, MRSA and the scary new Actinobacter buneii from the Iraq war. I saw here the first day in full chemical warfare gear, but have been told since that students aren't supposed to expose themselves and risk spreading it around.
It is a travesty that she's getting every antibiotic, imaging study and specialty consult available. The family, I assume for some cultural reason, won't unplug her and let her pass even though there's no where but down to go from here. And can you believe I was called in on this case to disimpact her!! At this hospital Medicine turfs those fun jobs over to surgery. I wonder if we're at this point because they are also avoiding the heart-to-heart conversation with the patient's family (through an interpreter).
From what I've been told, none of the family speaks English or is here legally either, so the whole thing certainly leaves an anti-immigration taste in my mouth. It also highlights some of the huge problems in our medical-legal system. As one of the Indian Attendings said, the only country in the world this could happen is the USA.
Rounding is getting easier. I'm getting more efficient at the brief physical exam and progress note. I still miss knowing the whole picture on patients, but I only have time to check on GI and surgery-related issues. Plus, there's usually other specialists or primary care docs on board to address everything else.
Our third student is a decent guy, but I sure started the week miffed about giving up a third of the cases. We'll see how this works out, but so far I only feel like he's taken some office visits - which is just fine.
Our intern and Chief resident (since he's the only resident in this new program) went away for the weekend so I house sat for him. It was a wonderful break from the "cell". I played with his boxer Griffin, got to use his Saab and slept on a real bed. Of course I stayed up too late on Friday enjoying cable TV again.
Rounding this weekend with our Surgeon on call as rewarding. Jason and I scrubbed in on a morning X lap (exploratory bowel surg) since the Chief was gone. We also had the opportunity to share everything we'd been assigned to read. Both of did very well according the surgeon and scrub tech. Jason didn't feel great, so he went home early. This gave me a lot of face time with my Attending. She spent a lot of time teaching and explaining things. It was SO much different than the classic arrogant surgeon-student relationship or the Medicine Attendings with God complexes I met at the VA. Now I have to read up on C. difficile and breast pathology.
One case is worth highlighting because it's so disturbing. We have a women who is an illegal alien getting an incredible amount of taxpayer funded care for no good reason other than her family isn't ready to let her go. The woman is a vegatable from a CVA, has a trach, and can't speak English anyway. Moreover, her kidneys, heart, liver and circulatory systems are collapsing. Finally she has ALL the superbugs: VRE, MRSA and the scary new Actinobacter buneii from the Iraq war. I saw here the first day in full chemical warfare gear, but have been told since that students aren't supposed to expose themselves and risk spreading it around.
It is a travesty that she's getting every antibiotic, imaging study and specialty consult available. The family, I assume for some cultural reason, won't unplug her and let her pass even though there's no where but down to go from here. And can you believe I was called in on this case to disimpact her!! At this hospital Medicine turfs those fun jobs over to surgery. I wonder if we're at this point because they are also avoiding the heart-to-heart conversation with the patient's family (through an interpreter).
From what I've been told, none of the family speaks English or is here legally either, so the whole thing certainly leaves an anti-immigration taste in my mouth. It also highlights some of the huge problems in our medical-legal system. As one of the Indian Attendings said, the only country in the world this could happen is the USA.
Sunday, February 04, 2007
First week of surgery
The week has gotten better. Still feels like we've had no orientation and we're flying by the seat of our pants. But the very helpful and somewhat obnoxious MSIII student shared his wisdom with Jason and I and left for his next rotation. Even better, our new resident is an English speaking intern that likes to teach.
We may learn something yet. If nothing else, I think I'll be able to perform a cholecystectomy myself after this rotation. I scrubbed in for about my fourth gallbladder removal on Friday and am getting pretty good on the camera and closing up. Suturing with gloves is still tricky, so I spent some time practicing last night while watching a movie in the room. Our intern (we call him Chief since he's the first DO surgical resident in the new program here) wants us to study fluid management and nutrition for Monday. So tomorrow is going to very busy preparing for my Peds rotation exam on Monday, studying fluids/nutrition and watching the Super Bowl. Oh, I also have to do laundry.
Yeah, I didn't get a lot done today unfortunately. I was exhausted from the first week. It's a lot more hours and more intense than Peds ER. So I slept in, did a couple errands and borrowed Jason's car. He was kind enough to loan it to me while he takes call this weekend. So I got in some grocery shopping and caught a movie, the very weird Pan's Labyrinth.
We have three surgeries scheduled for Monday, so the week looks pretty good so far. Then I'm going to do call next weekend. All these hours are certainly convincing me that surgery isn't my top choice. Even our attendings work like 90 hours a week. It's crazy.
At the same time I've exchanged a few e-mails with recent FP residency graduates that state my goal of a procedural, rural FP practice is very doable. I even got tips on how to get hospitals to bid against eachother tin order to get the most financial help with student loans and start-up costs. It still feels like a good fit, even though I might get a bit jealous of ER and Anesthesia when they make more on less hours.
One thing is for certain. Toledo isn't where we're going to end up. With the wind chill it's like 10 degrees below zero! The snow is blowing off the drifts into little clouds. Exposed hands get painfully numb just walking across the parking lot. The wind burns your ears and cheeks.
Time to get some sleep for a big day tomorrow.
We may learn something yet. If nothing else, I think I'll be able to perform a cholecystectomy myself after this rotation. I scrubbed in for about my fourth gallbladder removal on Friday and am getting pretty good on the camera and closing up. Suturing with gloves is still tricky, so I spent some time practicing last night while watching a movie in the room. Our intern (we call him Chief since he's the first DO surgical resident in the new program here) wants us to study fluid management and nutrition for Monday. So tomorrow is going to very busy preparing for my Peds rotation exam on Monday, studying fluids/nutrition and watching the Super Bowl. Oh, I also have to do laundry.
Yeah, I didn't get a lot done today unfortunately. I was exhausted from the first week. It's a lot more hours and more intense than Peds ER. So I slept in, did a couple errands and borrowed Jason's car. He was kind enough to loan it to me while he takes call this weekend. So I got in some grocery shopping and caught a movie, the very weird Pan's Labyrinth.
We have three surgeries scheduled for Monday, so the week looks pretty good so far. Then I'm going to do call next weekend. All these hours are certainly convincing me that surgery isn't my top choice. Even our attendings work like 90 hours a week. It's crazy.
At the same time I've exchanged a few e-mails with recent FP residency graduates that state my goal of a procedural, rural FP practice is very doable. I even got tips on how to get hospitals to bid against eachother tin order to get the most financial help with student loans and start-up costs. It still feels like a good fit, even though I might get a bit jealous of ER and Anesthesia when they make more on less hours.
One thing is for certain. Toledo isn't where we're going to end up. With the wind chill it's like 10 degrees below zero! The snow is blowing off the drifts into little clouds. Exposed hands get painfully numb just walking across the parking lot. The wind burns your ears and cheeks.
Time to get some sleep for a big day tomorrow.
Subscribe to:
Posts (Atom)