Surgery ended just fine. Dr. Greco let me do more incisions, my sutures were looking better than ever and I wielded the Bovey decently. It's only been two days and I'm already missing the OR. There's something special about that place.
You, as the surgeon, are the boss as only a Navy Captain on the high seas can experience. The patient's wellbeing is your direct responsibility so you govern everything that happens. Unlike a Captain, you use your hands and mind to fix someone. You have to stay on top of meds, coags, fluids, nutrition, co-morbidities, H&H, pain, patient comfort (they can't feel abrasions) and more. And of course, it's fairly technical. There's some old tech (forceps, scissors) mixed in with a ton of new tech (Ligasure, GIA, A-grams, mesh, etc.).
I still believe the sacrifice is too great on family to go through five years of Jedi Knight/monk training (total dedication). Plus I'm long past my twenties. So it's kind of a sad farewell to the specialty. I may have rotations in surgery during Residency, and I may get opportunities to first assist for my patients in practice, but I'll never look through my mask/visor at my double-gloved hands in someone's abdomen with the sense that this could be my career.
The shelf test on Friday was ok, but some questions were ridiculous. As an example, one asked what anatomical anomaly causes hernias. Uhm, what kind of hernia? Incisional and spigellian are rectus sheath defects. Direct Inguinal are tranversalis fascia. Indirect Inguinal are from a patent process vaginalis. You get the idea...
I think I passed, and that's really all that matters. But I learned so much surgical knowledge and skills, I had hoped to do really well. Our Clinical Education is too amateurish for fair assessment, hence the Pass/Fail grading system.
The boys did very well in their first "real" swim meet yesterday. Now we have times for them to beat next season. In Phoenix the season ends in Spring because it's too hot to hold outdoor meets in the Summer! They really like their coach, so they will probably swim through the summer. This assumes Becky and I can work out childcare between her job, my didactics and Boards preparation and both of our work-out schedules. After the meet we prepared for Connor's 11th B-day sleepover. Any remaining time I've spent preparing for the Fort Wayne trip.
Becky and I are determined to get into better shape and lose some weight, but it's difficult with my travel. I read that there's a pool I can use in Fort Wayne, and I'll have a car. Plus the hours shouldn't be the 80+ schedule of surgery. Regardless is going to be a long month of hospital food, uncomfortable beds, new people and jobs, etc. I just hope that the three weeks of Family and one week of Emergency will give me the information and firsthand experience necessary to decide which specialty is the best fit.
I still have to finish the paperwork for my research rotation after Fort Wayne. I'm looking forward to the reduced hours, close proximity and return to some research. But I really hope the exposure to RadOnc will be enough to rule it out or make me 100% sure it's worth the effort to go for. The 70 or so spots across the country are so competitive you have to prepare extremely well for interviews and applications. I just heard that one of our MSIV classmates was thinking Psych and changed to RadOnc late, then matched at a great program! I have to find out who it is and talk to this person.
Almost forgot, I spent time with the radiologist in Show Low checking out what they do. I love the interventional part of it. Placing tubes, running A-grams and nuclear studies, placing rads guided markers and lines, etc. But they spend a lot of time in dark rooms with big screens rapidly talking into their microphones. Procedures with actual patients are their breaks. They try to dictate 100+ studies per day. I'm too much of a people person to be happy in Rads.
Of course Rads has reasonable hours and makes a truckload of dough. I think Rads, Derm and Anesthesia are examples of overpaid specialties. They all make more than surgeons while surgeons have more responsibility, at least as long residencies, higher malpractice, worse hours and more stress. And Medicare wants to reduce their compensation 25% in the next few years! That just doesn't make any sense at all.
An hour or so until we drive to the airport. I sure hope this month is going to be worth it...
Sunday, March 25, 2007
Wednesday, March 21, 2007
One year to go for the Match
The MSIV medical students from around the country received the results of the Match last week. Actually the military, married and osteopathic students had earlier matches, but by now everyone should know where they are going come June.
That means the countdown for my class has begun. As usual I'm having a hard time studying for my Surgery shelf test on Friday because my tunnel vision is focused on residency programs. I have my EM draft spreadsheet, but need to research the programs so I can rank them. Even though I'm not decided on Emergency Medicine (EM) I have one audition rotation scheduled in September at an Osteopathic program. Now I need to schedule another EM rotation at an East Coast allopathic program. Along with EM at Maricopa County in Phoenix, that will give me a well-rounded CV with a good assortment of Letters of Recommendation (LORs).
As for the rotation, it's going very well. I hung out with one of the radiologists yesterday afternoon, and while I love the money and lifestyle, I couldn't do it. They fly through imaging consults, dictations and studies in the "pit" (e.g. dungeon) with too few patient encounters for procedures in between. Dr. Greco called me in late for an acute appendicitis. It was a great case of a week long ruptured appendix. He let me cut, suture and break-up some of the nasty pus pockets. She had a lot of co-morbidities but she should do just fine after a week of ventilation, antibiotics and open abdominal wound packing. I love surgery. It's just too bad it's such a sacrifice lifestyle-wise. I might even overlook my somewhat advanced age if it wasn't an all consuming profession. 5am until 6pm on normal days with overnight call once or twice a week is just too much.
I went home over the weekend. The family and I went to Body Worlds 3 on Saturday and had a great time. Colton got bored after an hour and a half of my detailed explanations on the anatomy, physiology and pathology of the cadaveric displays, but Connor pretended to be interested for another hour or so. Colton summed it up by saying; "being a surgeon would be pretty cool." While there I ran into a couple AZCOM fourth years. They had a big post-Match party Friday and most students were very happy. Twelve had to scramble for residencies, but it sounded like many of them didn't list enough choices and "blackholed" themselves.
We then enjoyed a 96 degree March afternoon in Phoenix and went to dinner at some friends' house. We had Tucker and his family over on Sunday for a relaxing day of barbequing and chatting.
I drove back to Show Low on Monday taking the long route through Globe and was again amazed by the beautiful scenery. Until you see Sedona and the eastern mountain ranges (Superstition, Mongollan, White) you have no idea how beautiful a state this is. Phoenix is really one of the ugliest places in this state.
Finally, I officially changed my last rotation of this year from rural family here in Show Low to research with Dr. Reed, the RadOnc I shadowed in second year. He's doing some research with the help of one of my classmates and mentioned could use mine too. It will be close to home, an easy schedule (convenient for Step 2 Boards studying) and give me a chance to ask Dr. Kresl if he's ever going to publish the case study I did with a fourth year classmate on Gamma Knife therapy. The only downside is that I have to go back to campus for didactics every other Tuesday. Oh well...
That means the countdown for my class has begun. As usual I'm having a hard time studying for my Surgery shelf test on Friday because my tunnel vision is focused on residency programs. I have my EM draft spreadsheet, but need to research the programs so I can rank them. Even though I'm not decided on Emergency Medicine (EM) I have one audition rotation scheduled in September at an Osteopathic program. Now I need to schedule another EM rotation at an East Coast allopathic program. Along with EM at Maricopa County in Phoenix, that will give me a well-rounded CV with a good assortment of Letters of Recommendation (LORs).
As for the rotation, it's going very well. I hung out with one of the radiologists yesterday afternoon, and while I love the money and lifestyle, I couldn't do it. They fly through imaging consults, dictations and studies in the "pit" (e.g. dungeon) with too few patient encounters for procedures in between. Dr. Greco called me in late for an acute appendicitis. It was a great case of a week long ruptured appendix. He let me cut, suture and break-up some of the nasty pus pockets. She had a lot of co-morbidities but she should do just fine after a week of ventilation, antibiotics and open abdominal wound packing. I love surgery. It's just too bad it's such a sacrifice lifestyle-wise. I might even overlook my somewhat advanced age if it wasn't an all consuming profession. 5am until 6pm on normal days with overnight call once or twice a week is just too much.
I went home over the weekend. The family and I went to Body Worlds 3 on Saturday and had a great time. Colton got bored after an hour and a half of my detailed explanations on the anatomy, physiology and pathology of the cadaveric displays, but Connor pretended to be interested for another hour or so. Colton summed it up by saying; "being a surgeon would be pretty cool." While there I ran into a couple AZCOM fourth years. They had a big post-Match party Friday and most students were very happy. Twelve had to scramble for residencies, but it sounded like many of them didn't list enough choices and "blackholed" themselves.
We then enjoyed a 96 degree March afternoon in Phoenix and went to dinner at some friends' house. We had Tucker and his family over on Sunday for a relaxing day of barbequing and chatting.
I drove back to Show Low on Monday taking the long route through Globe and was again amazed by the beautiful scenery. Until you see Sedona and the eastern mountain ranges (Superstition, Mongollan, White) you have no idea how beautiful a state this is. Phoenix is really one of the ugliest places in this state.
Finally, I officially changed my last rotation of this year from rural family here in Show Low to research with Dr. Reed, the RadOnc I shadowed in second year. He's doing some research with the help of one of my classmates and mentioned could use mine too. It will be close to home, an easy schedule (convenient for Step 2 Boards studying) and give me a chance to ask Dr. Kresl if he's ever going to publish the case study I did with a fourth year classmate on Gamma Knife therapy. The only downside is that I have to go back to campus for didactics every other Tuesday. Oh well...
Thursday, March 15, 2007
Career schizophrenia
Today was another decent day medically. Assisted on bilateral inguinal hernia repairs in a one-year-old boy. Scoped a true Ulcerative Colitis.
Even heard a good joke related to specialties. Where do you hide a dollar bill from a:
Internist... taped to his patient
Surgeon... with his wife
Orthopod... in a book
Plastic Surgeon... no where, he'll find it anywhere
I'm still coming back from yesterday's disappointment's. Had a long conversation with one of my preceptors about specialties and the future of medicine. If you spend any time looking at the numbers you can get very pessimistic. I'm starting to feel a little jaded just as many Docs and professors predicted would happen during third and fourth year. My biggest angst at the moment is that I don't feel any specialty truly "fits" and I've got start making some plans for fourth year audition rotations quickly.
I hope it comes to me quickly...
Even heard a good joke related to specialties. Where do you hide a dollar bill from a:
Internist... taped to his patient
Surgeon... with his wife
Orthopod... in a book
Plastic Surgeon... no where, he'll find it anywhere
I'm still coming back from yesterday's disappointment's. Had a long conversation with one of my preceptors about specialties and the future of medicine. If you spend any time looking at the numbers you can get very pessimistic. I'm starting to feel a little jaded just as many Docs and professors predicted would happen during third and fourth year. My biggest angst at the moment is that I don't feel any specialty truly "fits" and I've got start making some plans for fourth year audition rotations quickly.
I hope it comes to me quickly...
More fun in Show Low
It's been a great two and a half weeks in Show Low. I like the place and it's been a valuable learning experience. Moreover, it's been pretty relaxing. I haven't spent much time in clinic or rounding on patients here at the hospital. On slow days, like yesterday, I've been able to spend some time in the ER learning more about Emergency Medicine.
EM in this rural environment is interesting. You get to know the locals well (too well in some cases) and do a lot of procedures. I think compensation is pretty good as well. The specialty "feels" pretty good. But I'm not totally convinced. I still have questions about burnout, why none of the EM docs like to do procedures and how the EM "business" is set up. I had a conversation regarding the latter yesterday and was surprised to hear the Docs here have their own businesses and charge the hospital for their services. There's almost no overhead, so the compensation is higher than, say, Family Medicine. But I'm not sure who sets wages, how vacation time, overtime (extra shifts) and retirement benefits are set.
Yesterday was fine educationally, but a real downer career wise. I thought I had an EM rotation set up at UCSD for the last rotation of the year. I even talked with the EM coordinator and she said the Program Director was fine with my rotation, so it was a "done deal". Then I got a voice mail a few hours later that the UC bureaucrats nixed the rotation because I am only a third year student. I grabbed the FP rotation here in Show Low I had previously scheduled. But I'm disappointed that I'm going to spend my one elective this year in Family Medicine. I'll have three Family rotations under my belt already and no exposure to EM, anesthesia or radiology!
My fourth year rotation schedule came through yesterday as well. I only recognized two names from the list I submitted for the lottery last month. In talking with a classmate, I'm not the only one feeling screwed. Moreover, I received a reminder that my LORs for Maricopa County rotations are now late and may jeopardize those fourth year rotations. Ugh! Time to hound my Docs about the LORs they promised. And possibly time to start calling EM (or gas/rads) Docs about simply shadowing them for my last rotation this year.
As for surgery, the week and a half since my last post has been great. I've burned three gallbladders off patients' livers. I've intubated a few times and run into a couple very challenging anatomies. I've assisted in three thyroidectomies now, three more than last month. I was given the opportunity to remove an appendix so I got some firsthand experience with a GIA - a VERY fancy stapler that laparascopically places four rows of staples and then cuts down the middle of the rows. If surgery didn't have such an awful lifestyle, torturous residency and mediocre pay it would be very enticing. If I was ten years younger, you still couldn't keep me away.
Oh, in the ER I even stitched up a young lesbian's forearm after a self-inflicted serrated knife wound through part of her brachioradialis muscle. Fun stuff!
Finally, the wife and kids spent the weekend here with me. We had a good time hanging out Saturday and skiing Sunday. The skiing here was a bit icy in the morning and slushy in the late afternoon, but quite respectable. Connor took a little longer to remember how to balance, but by lunch both boys were bombing down the mountain. Dr. Greco, my preceptor, even managed to find me on one of my solo runs from the top. I think he's the best boarder I've seen so far. Even with his iTunes going and Bluetooth earpiece ready to pick-up any emergencies (he was on call!) he flew down the mountain with amazing grace. Typical surgeon, he doesn't do anything halfway!
This weekend we take the kids to BodyWorlds and I get a year older. If I can keep swimming 3-4 times per week and lose a few pounds, maybe the birthdays won't be such a downer. I love not having traffic here in rural Show Low. I get up at 6am, am in the water by 6:20, out by 7:10 and back at the hospital in scrubs ready for surgery by 7:30am! At 6500 ft above sea level, I can only do 1800 yards, but hope to get up to 2k in the same time by next week without sucking air too badly.
Friday, March 02, 2007
First week in Show Low
Just got back to the family in Phoenix after a great week in Show Low, AZ.
First, the town is great. One of those hidden gems that you know will be overgrown in the next few years, but is the ideal size now. It's 3-4 hours outside of Phoenix with weather like Colorado: lots of sunny days, seasons, trees/vegetation, and skiing/mountains nearby. Only thing missing is the ocean, but even that is only 7 or so hours away (Rocky Point, Mexico).
The medical training is great as well. The surgeons are laid back, and because I've had some surgery now, they are letting me do a ton. It also helps that there's no other students or interns to share procedures with. The highlight of the week is 4 intubations, Lap dissection of a gallbladder from the liver and first assisting on some cool surgeries like Lap Nissens (wrapping the stomach around the esophagus to eliminate hiatal hernias). I'm also getting much better on my knots. Interupted knots are second nature and I'm getting the hand of fancy buried-knot, subcutaneous sutures.
I'm not managing patients or doing much clinic time, so it's mostly just OR time and reading on my own. The staff at the hospital, outpatient surgery clinic and surgeons' office are great. Even the apartment is a huge improvement over Toledo. Becky and the boys are planning to join me next weekend in Show Low to see the town and get in a day of skiing. I think Becky will love the drive. It's so scenic you begin think Arizona is a beautiful state and Sedona isn't an accident.
Lots are errands to finish up this weekend: logs, test schedules, evals and possibly a change in my last rotation this year. I'm looking pretty hard at Emergency Medicine and would like to change my last rotation, rural Family here in Show Low, to an EM rotation. My roommate is doing the rural FP rotation and I just don't think I will learn as much regarding specialty choices versus spending a month in an ER. I may even get to do a couple ER shifts in Show Low this month, then in Ft. Wayne next month to get a taste of the job.
I've had some great conversations with classmates regarding FP versus EM. My roommate this month and one of my class friends (whose wife happens to be my kids' piano teacher) are both in the same position, trying to decide between specialties and individual programs. I need to get started on the spreadsheet and phone calls regarding about 6 western and 6-10 eastern EM programs that look intriguing at first glance.
Maybe the best thing about this rotation is that I have a car and can drive to a pool every morning. I found out about it on Tuesday so only got in two swims, at a very reasonable $2 per session. But I feel so much better with even a meager two workouts. The swims felt awful (I'm horribly out of shape) but I felt great afterwards. Without mornings free until the first surgery (around 8am usually) and a car, I should be able to get in 3-4 weekday swims plus some kind of activity on the weekend.
Time to get some rest back in my own bed.
First, the town is great. One of those hidden gems that you know will be overgrown in the next few years, but is the ideal size now. It's 3-4 hours outside of Phoenix with weather like Colorado: lots of sunny days, seasons, trees/vegetation, and skiing/mountains nearby. Only thing missing is the ocean, but even that is only 7 or so hours away (Rocky Point, Mexico).
The medical training is great as well. The surgeons are laid back, and because I've had some surgery now, they are letting me do a ton. It also helps that there's no other students or interns to share procedures with. The highlight of the week is 4 intubations, Lap dissection of a gallbladder from the liver and first assisting on some cool surgeries like Lap Nissens (wrapping the stomach around the esophagus to eliminate hiatal hernias). I'm also getting much better on my knots. Interupted knots are second nature and I'm getting the hand of fancy buried-knot, subcutaneous sutures.
I'm not managing patients or doing much clinic time, so it's mostly just OR time and reading on my own. The staff at the hospital, outpatient surgery clinic and surgeons' office are great. Even the apartment is a huge improvement over Toledo. Becky and the boys are planning to join me next weekend in Show Low to see the town and get in a day of skiing. I think Becky will love the drive. It's so scenic you begin think Arizona is a beautiful state and Sedona isn't an accident.
Lots are errands to finish up this weekend: logs, test schedules, evals and possibly a change in my last rotation this year. I'm looking pretty hard at Emergency Medicine and would like to change my last rotation, rural Family here in Show Low, to an EM rotation. My roommate is doing the rural FP rotation and I just don't think I will learn as much regarding specialty choices versus spending a month in an ER. I may even get to do a couple ER shifts in Show Low this month, then in Ft. Wayne next month to get a taste of the job.
I've had some great conversations with classmates regarding FP versus EM. My roommate this month and one of my class friends (whose wife happens to be my kids' piano teacher) are both in the same position, trying to decide between specialties and individual programs. I need to get started on the spreadsheet and phone calls regarding about 6 western and 6-10 eastern EM programs that look intriguing at first glance.
Maybe the best thing about this rotation is that I have a car and can drive to a pool every morning. I found out about it on Tuesday so only got in two swims, at a very reasonable $2 per session. But I feel so much better with even a meager two workouts. The swims felt awful (I'm horribly out of shape) but I felt great afterwards. Without mornings free until the first surgery (around 8am usually) and a car, I should be able to get in 3-4 weekday swims plus some kind of activity on the weekend.
Time to get some rest back in my own bed.
Saturday, February 24, 2007
Back home...finally
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.
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.
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.
Tuesday, January 30, 2007
Starting Surgery
Well the first two days have been pretty anti-climatic. The rotation isn't really ward-based as I had hoped. It's more like a preceptor-based rotation that happens to have Residents as First Assist or Surgeon at one of the four hospitals we work at. Yes, that's four hospitals to go to for surgeries and to call on patients every morning. Kind of difficult when I have no car and it's fourteen degrees outside. My fellow MSIII student has been kind enough to give me rides so far. And there's absolutely no orientation or Resident teaching, so it feels like flying by the seat of your pants. We do get some didactics, but they seem vastly inferior to the ER lectures from last month.
All the surgeries so far have been gallbladder related. I stayed up late last night studying surgery on the biliary tract for a long open cholecystectomy this morning. Usually gallbladder removal is done with scopes through small incisions, but this patient had enormous stones that had to be manually removed in the bile ducts and all the way up into the liver. It took hours using tiny balloons and mesh cages to fish them out. My job thusfar has been holding retractors, suctioning and a little stapling. I've only rounded on one patient so far. The good thing is that we only have to write short SOAP (progress) notes instead of H&Ps. If we have 8am surgeries, that means days start around 6:30am in order to have enough time to see patients and write notes.
One of the reasons I'm not doing more in the OR is that we have an extra student in our normally two student service. He's off schedule so he's got one more week with us. That means he's been able to help us figure where we're supposed to be and what we're supposed to be doing. But it also means that we have three students trying to scrub in on a limited number of surgeries.
The surgeons themselves seem ok. A little ornery, but certainly not arrogant. So far the teaching has been mediocre, but I hope that it improves as we get up to speed and the third student heads out. I'm holding onto my hope that things will improve after the first week like they did with Peds last month.
Tonight I hope to study some Peds for my test on Monday. At least I have a full weekend to prepare. That also means there won't be too much time to miss the family. Who knows, maybe I'll even get motivated to work out a bit.
All the surgeries so far have been gallbladder related. I stayed up late last night studying surgery on the biliary tract for a long open cholecystectomy this morning. Usually gallbladder removal is done with scopes through small incisions, but this patient had enormous stones that had to be manually removed in the bile ducts and all the way up into the liver. It took hours using tiny balloons and mesh cages to fish them out. My job thusfar has been holding retractors, suctioning and a little stapling. I've only rounded on one patient so far. The good thing is that we only have to write short SOAP (progress) notes instead of H&Ps. If we have 8am surgeries, that means days start around 6:30am in order to have enough time to see patients and write notes.
One of the reasons I'm not doing more in the OR is that we have an extra student in our normally two student service. He's off schedule so he's got one more week with us. That means he's been able to help us figure where we're supposed to be and what we're supposed to be doing. But it also means that we have three students trying to scrub in on a limited number of surgeries.
The surgeons themselves seem ok. A little ornery, but certainly not arrogant. So far the teaching has been mediocre, but I hope that it improves as we get up to speed and the third student heads out. I'm holding onto my hope that things will improve after the first week like they did with Peds last month.
Tonight I hope to study some Peds for my test on Monday. At least I have a full weekend to prepare. That also means there won't be too much time to miss the family. Who knows, maybe I'll even get motivated to work out a bit.
Saturday, January 27, 2007
Peds down, halfway thru Toledo confinement
I finished the Pediatric ER rotation on Wednesday. Tuesday was my last shift in the ER. It was busy and the time passed quickly. Nothing too unusual, but good learning cases. At the end, my Attending gave me a glowing evaluation. I'm not sure how the Doc that actually pens my evaluation for the entire rotation will use it, but it sure felt good. I had had this Attending for most of my shifts, but he had always just checked off "performing as expected" on my daily log sheets. The paragraph or so he wrote was my first real feedback on my performance.
Wednesday I was coming down with a cold so I didn't do a procedural shift in the ER like I had intended. My only required duty was some mock codes with three other students on a $40k doll. A second year ER Resident instructed us while a tech handled the computer operation for the doll. This doll could be male or female. It breathed, cried, opened its eyes, bled, had heart and lung sounds, fractures and much more. We did scenarios like head injuries where the doll had one blown pupil and chest injuries with a tension pneumothorax and cardiac tamponade. Of course, we also had the AMI with ECG readout where we had to intubate (RSI) and run an ACLS code.
Pig lab a week or so prior was similar, but a first year Resident and I performed several procedures on a live (anesthetized) pig before it was put to sleep. It was a little weird (and smelly) but a great experience. I put in an IO line, did an LDP, pleuracentesis, cardiocentesis, chest tube and cricothyroidotomy. One procedure shift wouldn't have come close to that experience.
Interesting cases in the last two weeks included sickle cell crisis, respiratory distress, croup, an ovarian cyst that turned out to be GC, Candida and UTI, sunflower shell impaction, lots of fractures and lacerations. I sutured a bunch, did a digital block, stapled a scalp lac and helped set a couple fractures. And I had all the AOM, RSV, rotovirus, etc. that I would have been inundated with at a Pediatric office.
So was it worth leaving Phoenix, my family and all the comforts of home for this learning opportunity? Wow, that is still a tough question. I like to think so. It certainly gave me more exposure to Emergency Medicine than most MSIII students get. For a single student interested in ER, you could do a lot worse that St. Vincent's. The Attendings, Residents and fellow students were great: nice, interested in teaching and without any arrogance.
Now that I'm home though, I'm not looking forward to flying back to Toledo tomorrow for surgery. It's been a great couple of days with the boys and Becky - and the dogs. I didn't think I would appreciate the sunshine this much. Seventy degrees and sunny in the middle of January is pretty darn nice! I drank too much red wine last night ending my month of celibacy and sobriety. Tonight is Gray's Anatomy catch-up. Tomorrow I have just enough time for a lazy morning, packing some khakis, dress shirts and ties so I can look like a proper surgeon, and then it's off to the airport.
I hope I can get through the remainder of my Pediatrics book on the flights back. I have to take my rotation test in the next week or so. And at this point, I feel more prepared for an ER test. Time to hit the books.
Wednesday I was coming down with a cold so I didn't do a procedural shift in the ER like I had intended. My only required duty was some mock codes with three other students on a $40k doll. A second year ER Resident instructed us while a tech handled the computer operation for the doll. This doll could be male or female. It breathed, cried, opened its eyes, bled, had heart and lung sounds, fractures and much more. We did scenarios like head injuries where the doll had one blown pupil and chest injuries with a tension pneumothorax and cardiac tamponade. Of course, we also had the AMI with ECG readout where we had to intubate (RSI) and run an ACLS code.
Pig lab a week or so prior was similar, but a first year Resident and I performed several procedures on a live (anesthetized) pig before it was put to sleep. It was a little weird (and smelly) but a great experience. I put in an IO line, did an LDP, pleuracentesis, cardiocentesis, chest tube and cricothyroidotomy. One procedure shift wouldn't have come close to that experience.
Interesting cases in the last two weeks included sickle cell crisis, respiratory distress, croup, an ovarian cyst that turned out to be GC, Candida and UTI, sunflower shell impaction, lots of fractures and lacerations. I sutured a bunch, did a digital block, stapled a scalp lac and helped set a couple fractures. And I had all the AOM, RSV, rotovirus, etc. that I would have been inundated with at a Pediatric office.
So was it worth leaving Phoenix, my family and all the comforts of home for this learning opportunity? Wow, that is still a tough question. I like to think so. It certainly gave me more exposure to Emergency Medicine than most MSIII students get. For a single student interested in ER, you could do a lot worse that St. Vincent's. The Attendings, Residents and fellow students were great: nice, interested in teaching and without any arrogance.
Now that I'm home though, I'm not looking forward to flying back to Toledo tomorrow for surgery. It's been a great couple of days with the boys and Becky - and the dogs. I didn't think I would appreciate the sunshine this much. Seventy degrees and sunny in the middle of January is pretty darn nice! I drank too much red wine last night ending my month of celibacy and sobriety. Tonight is Gray's Anatomy catch-up. Tomorrow I have just enough time for a lazy morning, packing some khakis, dress shirts and ties so I can look like a proper surgeon, and then it's off to the airport.
I hope I can get through the remainder of my Pediatrics book on the flights back. I have to take my rotation test in the next week or so. And at this point, I feel more prepared for an ER test. Time to hit the books.
Saturday, January 13, 2007
Peds ER halfway point
Five of eleven shifts down, one of two EMS rides down and two weeks of didactics completed. I still haven't done any procedural shifts, but I hope to fit in one or two i n next two weeks. I'm also finally beginning to get study time in. I've been reading a couple hours a day for the last few after realizing that I'm getting more training in ER than Peds.
If I'm going to pass the shelf test in a few weeks, I'm going to have to learn most of the Peds material on my own.
As for cases, I've seen a lot of interesting stuff. Here's a sampling:
Status epilepticus
Febrile seizure
Crohn's Dz
Physical abuse
Refractory SVT (finally cardioverted with defib)
Diaphragmatic hernia w/ pulmonary hypoplasia
Lots of fractures and lacerations
Lots of Asthma, Pneumo and UTIs, but less Strep and Otitis Media than I expected.
I've had a chance to do casting, sutures, lots of physicals and observe a couple codes now. Surprisingly, my EMS ride day was boring. We had two real calls, one for tachycardia and one for syncope/drop-seizure. We also got called on a fire, but it was a non-event. At least the food was great. The firefighters and paramedics seem to be pretty good cooks.
As usual, this rotation has forced me to consider whether I would like, in this case, ER. Certainly the pay and time off are very attractive. Twelve to fourteen shifts a month of eight to twelve hours with no call for over two hundred a year. But you never see much of the patient, never get to do preventative medicine and don't get closure on many patients. The burnout rate is pretty high and you almost have to work in a hospital ER.
On the balance, ER doesn't surpass Family Practice. You don't make quite as much in FP, but have so much flexibility in your career: procedures, type of practice, location, patient population, etc. Plus you get to know the community and your patients much more. While many of the ER Residents and Attendings are pretty nice, I also identify with FP docs better. The surgical and IM specialists, even ER to a lesser degree, can be pretty high strung, arrogant and worn out.
The Residents switched over yesterday, so for tonight's shift I will be with ER Residents new to the Peds ER. Should be interesting.
If I'm going to pass the shelf test in a few weeks, I'm going to have to learn most of the Peds material on my own.
As for cases, I've seen a lot of interesting stuff. Here's a sampling:
Status epilepticus
Febrile seizure
Crohn's Dz
Physical abuse
Refractory SVT (finally cardioverted with defib)
Diaphragmatic hernia w/ pulmonary hypoplasia
Lots of fractures and lacerations
Lots of Asthma, Pneumo and UTIs, but less Strep and Otitis Media than I expected.
I've had a chance to do casting, sutures, lots of physicals and observe a couple codes now. Surprisingly, my EMS ride day was boring. We had two real calls, one for tachycardia and one for syncope/drop-seizure. We also got called on a fire, but it was a non-event. At least the food was great. The firefighters and paramedics seem to be pretty good cooks.
As usual, this rotation has forced me to consider whether I would like, in this case, ER. Certainly the pay and time off are very attractive. Twelve to fourteen shifts a month of eight to twelve hours with no call for over two hundred a year. But you never see much of the patient, never get to do preventative medicine and don't get closure on many patients. The burnout rate is pretty high and you almost have to work in a hospital ER.
On the balance, ER doesn't surpass Family Practice. You don't make quite as much in FP, but have so much flexibility in your career: procedures, type of practice, location, patient population, etc. Plus you get to know the community and your patients much more. While many of the ER Residents and Attendings are pretty nice, I also identify with FP docs better. The surgical and IM specialists, even ER to a lesser degree, can be pretty high strung, arrogant and worn out.
The Residents switched over yesterday, so for tonight's shift I will be with ER Residents new to the Peds ER. Should be interesting.
Today's Headlines
I had a chance to catch up on some news today, and a few issues got my attention.
I just have to mention that I'm surprisingly happy with the shake-up Speaker Pelosi is spear-heading in DC. I like the Government Guaranteed Loan plan that will be up for vote shortly. It sure would make it easier for middle to lower class medical students to choose primary care careers. Even more though, the Medicaid bill that just passed is much than the symbolic waste of paper the Republicans are trying to make it out as. It's their arguments that are wasted paper and air.
First, it will give our tax dollars the same buying power as individuals, corporations and other countries around the world have. Second, it will nail those Republicans with their hands in the Pharm cookie jar. Bravo to the New Demos, good move for American tax payers and great strategy for 2008.
Finally, on the Executive Branches' Stimson chastising Law firms for representing Guantanamo Bay detainees, so what? I think it's great that the firms' names are in public, so none of this representation in hiding. Let individual CEOs, Boards and Americans decide if they agree with Stimson. Law firms should be responsible for their actions. If they represent terrorists, child molesters, etc. they should do it openly. Stimson's actions are FAR, FAR less despicable than law firms who, in hiding, represent the worst of humanity in the name of fairness, then talk about how admirable they are.
It is far from admirable that they give away pro bono services to, at least in some cases, terrorists instead of good people who really need them: whistle blowers, single moms, etc. It would like Microsoft wanting to hide their giving PCs and software to the North Korean government in the name of fair education while our illiteracy rate here in the US climbs. It's almost as ridiculous as the 26,000 lawsuits filed against Merck for Vioxx. What a wasteful drain on the American economy at $200+ per hour per attorney. I bet we get ridiculed more for our legal practices around the world than our military actions. And there's no lameduck in legal greed.
I just have to mention that I'm surprisingly happy with the shake-up Speaker Pelosi is spear-heading in DC. I like the Government Guaranteed Loan plan that will be up for vote shortly. It sure would make it easier for middle to lower class medical students to choose primary care careers. Even more though, the Medicaid bill that just passed is much than the symbolic waste of paper the Republicans are trying to make it out as. It's their arguments that are wasted paper and air.
First, it will give our tax dollars the same buying power as individuals, corporations and other countries around the world have. Second, it will nail those Republicans with their hands in the Pharm cookie jar. Bravo to the New Demos, good move for American tax payers and great strategy for 2008.
Finally, on the Executive Branches' Stimson chastising Law firms for representing Guantanamo Bay detainees, so what? I think it's great that the firms' names are in public, so none of this representation in hiding. Let individual CEOs, Boards and Americans decide if they agree with Stimson. Law firms should be responsible for their actions. If they represent terrorists, child molesters, etc. they should do it openly. Stimson's actions are FAR, FAR less despicable than law firms who, in hiding, represent the worst of humanity in the name of fairness, then talk about how admirable they are.
It is far from admirable that they give away pro bono services to, at least in some cases, terrorists instead of good people who really need them: whistle blowers, single moms, etc. It would like Microsoft wanting to hide their giving PCs and software to the North Korean government in the name of fair education while our illiteracy rate here in the US climbs. It's almost as ridiculous as the 26,000 lawsuits filed against Merck for Vioxx. What a wasteful drain on the American economy at $200+ per hour per attorney. I bet we get ridiculed more for our legal practices around the world than our military actions. And there's no lameduck in legal greed.
Thursday, January 04, 2007
Made it to Toledo
Having lived in the Midwest for my first thirteen years, and spent some time here since then visiting relatives, I can see some attractive features of the area. But Toledo has none of these. As a fellow student from Athens, OH said; "Toledo has everything bad that goes along with being a big city, but none of the good." And she's an Ohio native. At least it's so cold, there's very little air pollution.
The trip here was horrible. First, the signs were confusing and I went through the wrong security gate, so I had a mile plus race around the airport hoping to get a standby seat on my flight. America West checked my bags to Toledo but couldn't find me a seat at the gate since the flight was oversold. No wonder I couldn't get a seat reserved online even a month ago. At the gate they finally decided to book me a flight with Continental that had one stop instead of two. It left an hour later, had a four hour lay-over in Cleveland, and still arrived a hour earlier than my original flight. Oh, and they gave me a free round trip ticket as compensation. That made up for several of the other little hassles like having to take a bus to another terminal, walking another mile and going through another security line.
Once I got to Toledo things got worse. The last leg of my original Delta flight, Cincinnati to Toledo, had been canceled. So my baggage was stuck in Cincinnati. However, my claim tickets were America West numbers. To sum up to confusion, I had American West bags in a Delta terminal but Continental was responsible for getting them to me now that I had flown in with them. And it wasn't easy finding anyone with a clue at 10pm in the little Toledo airport. Before taking a limo/taxi to the hospital I had assurances my baggage would be delivered to me the following day.
I finally made it to St. Vincent's hospital, picked up my housing information, badges and pager in the ER and headed for bed just after midnight. It had been a very stressful day. At least all the airport and airline personnel were nice. Even the majority of passengers were able to maintain a positive attitude.
Yesterday the bags arrived as promised. And nothing was broken or damaged! I went through my orientations, but then had the rest of the yesterday and today to wait around. I managed to get signed up for a couple extra shifts. So with 11 8-hour ER shifts, two EMS (ambulance) 8-hour shifts, two 8-hour procedure shifts and a bunch of didactics (from both the Peds and ER departments) my schedule is looking ok. Add in some Peds study time on my own and I hope to keep from getting too lonely and bored. There's nothing but crime in walking distance. I live in a 50-year old cell. And the place is almost vacant with only two other students in the "home away from home" dormitory.
The Admin said the place will be full in March, so I guess the storms are waiting for them this year. Toldeo hasn't had a snowflake so far this year. I just hope that doesn't mean I'm going to be grounded from one of my upcoming flights. At least I brought a bunch of pleasure and medical books. The free ticket will more than cover the overweight charge on my baggage and the shipping fee on the UPS box I shipped. As you can probably guess, I don't have a lot of practice packing for a two month trip to a different climate.
The people here are pretty nice considering. As my limo/taxi driver said; "if you don't drink and baseball season is over there isn't anything to do but work."
I finished a Sci-Fi book entitled Seeker yesterday about an Indiana Jones character in the far future. Very well written. I started Neverwhere today, but am not sure when I'll get it finished since I have to start studying Peds very soon. At least I finished one good pleasure book over the break.
The trip here was horrible. First, the signs were confusing and I went through the wrong security gate, so I had a mile plus race around the airport hoping to get a standby seat on my flight. America West checked my bags to Toledo but couldn't find me a seat at the gate since the flight was oversold. No wonder I couldn't get a seat reserved online even a month ago. At the gate they finally decided to book me a flight with Continental that had one stop instead of two. It left an hour later, had a four hour lay-over in Cleveland, and still arrived a hour earlier than my original flight. Oh, and they gave me a free round trip ticket as compensation. That made up for several of the other little hassles like having to take a bus to another terminal, walking another mile and going through another security line.
Once I got to Toledo things got worse. The last leg of my original Delta flight, Cincinnati to Toledo, had been canceled. So my baggage was stuck in Cincinnati. However, my claim tickets were America West numbers. To sum up to confusion, I had American West bags in a Delta terminal but Continental was responsible for getting them to me now that I had flown in with them. And it wasn't easy finding anyone with a clue at 10pm in the little Toledo airport. Before taking a limo/taxi to the hospital I had assurances my baggage would be delivered to me the following day.
I finally made it to St. Vincent's hospital, picked up my housing information, badges and pager in the ER and headed for bed just after midnight. It had been a very stressful day. At least all the airport and airline personnel were nice. Even the majority of passengers were able to maintain a positive attitude.
Yesterday the bags arrived as promised. And nothing was broken or damaged! I went through my orientations, but then had the rest of the yesterday and today to wait around. I managed to get signed up for a couple extra shifts. So with 11 8-hour ER shifts, two EMS (ambulance) 8-hour shifts, two 8-hour procedure shifts and a bunch of didactics (from both the Peds and ER departments) my schedule is looking ok. Add in some Peds study time on my own and I hope to keep from getting too lonely and bored. There's nothing but crime in walking distance. I live in a 50-year old cell. And the place is almost vacant with only two other students in the "home away from home" dormitory.
The Admin said the place will be full in March, so I guess the storms are waiting for them this year. Toldeo hasn't had a snowflake so far this year. I just hope that doesn't mean I'm going to be grounded from one of my upcoming flights. At least I brought a bunch of pleasure and medical books. The free ticket will more than cover the overweight charge on my baggage and the shipping fee on the UPS box I shipped. As you can probably guess, I don't have a lot of practice packing for a two month trip to a different climate.
The people here are pretty nice considering. As my limo/taxi driver said; "if you don't drink and baseball season is over there isn't anything to do but work."
I finished a Sci-Fi book entitled Seeker yesterday about an Indiana Jones character in the far future. Very well written. I started Neverwhere today, but am not sure when I'll get it finished since I have to start studying Peds very soon. At least I finished one good pleasure book over the break.
Holidays are over
Well the Holidays went pretty well after OB/Gyn ended without much fanfare. Nothing too exciting to report. I took the shelf test and passed just fine, but it was pretty hard. Glad I had a weekend to focus on it.
The first week of vacation was spent shopping for Xmas presents, putting up lights, decorating the house and running general errands. The Accord sure runs better after a tune-up.
It doesn't feel like I got much done. Certainly no studying. I made a concerted effort to not do any studying over the vacation to give myself a break. So for the first week I spent a lot of time with the family and relaxed. I really enjoyed red wine and rich food every night.
Xmas itself was a nice quiet affair. Christmas Eve the boys opened presents from Becky and I which included some cool Xbox/PC games, science kits and swimming stuff ("heart, mind and body"). The boys were thrilled with the games, but haven't touched the kits yet (but Connor's "Power House" will be incredibly useful for school science projects). The biggest disappointment was that Colton received two Nintendo DS games from my mom but no player. We explained that he would probably have enough money to save up for one on his own, and Connor, who is in on the know, suggested Santa might come to the rescue. There weren't tears, just a sad face.
Christmas morning that problem was solved by Santa. Connor received a cool remote plane/car that was given a rest only long enough to recharge the battery every 20-30 minutes. It's a cool design but the foam is light it's hard to control in the air. I was pretty sure the toy wouldn't survive day one. It did, but I think it won't be used too much once school starts. Connor would probably love a real remote plane with a rubber, but those are a few hundred dollars to start.
In the afternoon we had Tucker and his family over Christmas Day. The kids played together great. The meal was great. The wine was great. I love my new sunglasses and T-mobile MDA (after spending the better of a day installing about a dozen medical programs on it). It's so nice having one device now. Tucker and I didn't dwell too much on shop talk and the girls didn't bore us too much with endless discussion of their current fad - historical romance novels.
The second week was spent hosting family. First my Dad and step mom stayed over for a few days. I was too tired to play social coordinator, so I hope they weren't too disappointed with how little we actually did during their trip here. I met Tucker at school one afternoon and we figured out our MSIV rotation schedule. It was good to have two of us to look over reviews and compare Preceptors and hospitals. I changed a lot of my earlier selections and am pretty happy with the list I'm going to fax in for the computerized lottery today.
The advice we get from upperclassmen is have a relaxing fourth year and rest up for internship. So I have just two audition rotations scheduled, Ft. Collins and probably Ogden since I already know the Vancouver, WA area well. I'm still looking forward to Ft. Wayne in April but Becky has made it clear she's not crazy about the Midwest - and who can blame her?
Then my mom stayed over for New Year. She and the kids did a few fun things while I packed and got prepared for two months away. The boys and I also enjoyed playing Neverwinter Nights 2, but I think they went really crazy with Marvel Ultimate Alliance. They'll have teh game completed any day now. They cooperatively play different superheros and level them up to get new superpowers and outfits. Who knew Spiderman had such an extensive wardrobe? Lego Star Wars and Need For Speed: Carbon got high marks as well.
I certainly had a few second thoughts last week about this crazy schedule. Other than audition rotations next year, I don't plan to ever spend this much time away from the family again. I will miss the boys and Becky a lot. With Julie leaving as well, the dogs are going into a depression for sure.
The first week of vacation was spent shopping for Xmas presents, putting up lights, decorating the house and running general errands. The Accord sure runs better after a tune-up.
It doesn't feel like I got much done. Certainly no studying. I made a concerted effort to not do any studying over the vacation to give myself a break. So for the first week I spent a lot of time with the family and relaxed. I really enjoyed red wine and rich food every night.
Xmas itself was a nice quiet affair. Christmas Eve the boys opened presents from Becky and I which included some cool Xbox/PC games, science kits and swimming stuff ("heart, mind and body"). The boys were thrilled with the games, but haven't touched the kits yet (but Connor's "Power House" will be incredibly useful for school science projects). The biggest disappointment was that Colton received two Nintendo DS games from my mom but no player. We explained that he would probably have enough money to save up for one on his own, and Connor, who is in on the know, suggested Santa might come to the rescue. There weren't tears, just a sad face.
Christmas morning that problem was solved by Santa. Connor received a cool remote plane/car that was given a rest only long enough to recharge the battery every 20-30 minutes. It's a cool design but the foam is light it's hard to control in the air. I was pretty sure the toy wouldn't survive day one. It did, but I think it won't be used too much once school starts. Connor would probably love a real remote plane with a rubber, but those are a few hundred dollars to start.
In the afternoon we had Tucker and his family over Christmas Day. The kids played together great. The meal was great. The wine was great. I love my new sunglasses and T-mobile MDA (after spending the better of a day installing about a dozen medical programs on it). It's so nice having one device now. Tucker and I didn't dwell too much on shop talk and the girls didn't bore us too much with endless discussion of their current fad - historical romance novels.
The second week was spent hosting family. First my Dad and step mom stayed over for a few days. I was too tired to play social coordinator, so I hope they weren't too disappointed with how little we actually did during their trip here. I met Tucker at school one afternoon and we figured out our MSIV rotation schedule. It was good to have two of us to look over reviews and compare Preceptors and hospitals. I changed a lot of my earlier selections and am pretty happy with the list I'm going to fax in for the computerized lottery today.
The advice we get from upperclassmen is have a relaxing fourth year and rest up for internship. So I have just two audition rotations scheduled, Ft. Collins and probably Ogden since I already know the Vancouver, WA area well. I'm still looking forward to Ft. Wayne in April but Becky has made it clear she's not crazy about the Midwest - and who can blame her?
Then my mom stayed over for New Year. She and the kids did a few fun things while I packed and got prepared for two months away. The boys and I also enjoyed playing Neverwinter Nights 2, but I think they went really crazy with Marvel Ultimate Alliance. They'll have teh game completed any day now. They cooperatively play different superheros and level them up to get new superpowers and outfits. Who knew Spiderman had such an extensive wardrobe? Lego Star Wars and Need For Speed: Carbon got high marks as well.
I certainly had a few second thoughts last week about this crazy schedule. Other than audition rotations next year, I don't plan to ever spend this much time away from the family again. I will miss the boys and Becky a lot. With Julie leaving as well, the dogs are going into a depression for sure.
Monday, December 18, 2006
Does everything happen in droves?
Be forewarned: this is a rant more than a post. In addition to losing my car keys recently, I've lost my PDA, some notes from my cardiology rotation and who knows what else. Then today we get hit with expenses galore. Santa is bringing us a new refrigerator, new car tires, brake rotors, brake pads and a windshield. Yipee!
The one silver lining is that I've already ordered a new cell phone/PDA that is on the way. My PDA was showing it's age (I bought it used on Ebay) and I found a new T-mobile MDAs on Amazon for $25. I just hope it performs decently. I sure liked the Dash (Becky is getting one of those from Santa), but it wouldn't run most of my medical software (Windows Smartphone vs. Pocket PC). For another $30 I got a 2GB minSD card in case I ever purchase an UpToDate subscription for it.
As usual, my break will be spent (partially) working on choirs, gadgets and computers. It will be nice to have one device to carry around, but it's going to take some time setting up Epocrates, Feri's, Tabers, Netter's Anatomy, Ultimate Anatomy, Shots, Midnight Medical, Medical calculators, Outlook sync and the ones that I don't use on a daily basis. Somehow that seems more enjoyable than tackling the sprinkler system...again.
The one silver lining is that I've already ordered a new cell phone/PDA that is on the way. My PDA was showing it's age (I bought it used on Ebay) and I found a new T-mobile MDAs on Amazon for $25. I just hope it performs decently. I sure liked the Dash (Becky is getting one of those from Santa), but it wouldn't run most of my medical software (Windows Smartphone vs. Pocket PC). For another $30 I got a 2GB minSD card in case I ever purchase an UpToDate subscription for it.
As usual, my break will be spent (partially) working on choirs, gadgets and computers. It will be nice to have one device to carry around, but it's going to take some time setting up Epocrates, Feri's, Tabers, Netter's Anatomy, Ultimate Anatomy, Shots, Midnight Medical, Medical calculators, Outlook sync and the ones that I don't use on a daily basis. Somehow that seems more enjoyable than tackling the sprinkler system...again.
Sunday, December 17, 2006
Reflecting on a maternal death
While it's fresh, I wanted to post on an important but unpleasant topic. In the U.S. we do a pretty good with average maternal deaths around .01%. One of the top causes is maternal bleeding during labor & delivery. But it can also happen prior to labor due to improper implantation of the placenta.
In this case, the OB/Gyn group I worked with thought their patient had placenta previa where, by ultrasound, the placenta can be seen covering some of the cervix. This is a concern for bleeding but very rarely leads to a fatality. However, this patient had placenta acreta, where the placenta is implanted deep into the uterine muscle and its vasculature. There is currently no test or exam that diagnoses this condition. However, if placenta acreta is found incidentally, delivery is usually scheduled as early as possible (36-37 weeks) before contractions start.
This young lady of 28 was close to term with her second child. Previa bleeding was a concern at prenatal office visits, but she hadn't reported even any spotting. When she was admitted it was estimated that she'd lost almost half her blood volume. This was at 8am, not long after I had left Dr. Mourad in a C-section that ended my 7pm to 7am shift. He and ten or so other physicians from his group and perinatalogy rushed and frantically tried to get blood products into her hypotensive body, but could never gain on her profuse blood loss.
Resuscitation was attempted until 11am when the death of mother and child was called. I arrived that evening as scheduled at 7pm to find the entire labor & delivery unit in grief. Not tears, no one present at the bedside was still around, but real sadness from everyone coming on hearing the news like I did.
I talked to and overheard conversations from many nurses and several attending physicians from my group. I also heard from other physicians who made up a committee investigating the incident. My group even requested that the case be reviewed by an outside group of physicians (OB, perinatology and anesthesia) at a different hospital.
It sounds like the findings will be some minor procedural changes (chain of command, blood product availability) but nothing that would have changed the outcome. Now a five year old is left to be raised by his grandmother surely grieving for her daughter and unborn grandchild.
The whole case was an educational experience to go through, even from the outside. It showed a lot of care, humility and professionalism from my attendings. I don't look forward to experiencing my patient's death, but I feel a little more prepared for handling such an event.
In this case, the OB/Gyn group I worked with thought their patient had placenta previa where, by ultrasound, the placenta can be seen covering some of the cervix. This is a concern for bleeding but very rarely leads to a fatality. However, this patient had placenta acreta, where the placenta is implanted deep into the uterine muscle and its vasculature. There is currently no test or exam that diagnoses this condition. However, if placenta acreta is found incidentally, delivery is usually scheduled as early as possible (36-37 weeks) before contractions start.
This young lady of 28 was close to term with her second child. Previa bleeding was a concern at prenatal office visits, but she hadn't reported even any spotting. When she was admitted it was estimated that she'd lost almost half her blood volume. This was at 8am, not long after I had left Dr. Mourad in a C-section that ended my 7pm to 7am shift. He and ten or so other physicians from his group and perinatalogy rushed and frantically tried to get blood products into her hypotensive body, but could never gain on her profuse blood loss.
Resuscitation was attempted until 11am when the death of mother and child was called. I arrived that evening as scheduled at 7pm to find the entire labor & delivery unit in grief. Not tears, no one present at the bedside was still around, but real sadness from everyone coming on hearing the news like I did.
I talked to and overheard conversations from many nurses and several attending physicians from my group. I also heard from other physicians who made up a committee investigating the incident. My group even requested that the case be reviewed by an outside group of physicians (OB, perinatology and anesthesia) at a different hospital.
It sounds like the findings will be some minor procedural changes (chain of command, blood product availability) but nothing that would have changed the outcome. Now a five year old is left to be raised by his grandmother surely grieving for her daughter and unborn grandchild.
The whole case was an educational experience to go through, even from the outside. It showed a lot of care, humility and professionalism from my attendings. I don't look forward to experiencing my patient's death, but I feel a little more prepared for handling such an event.
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