Mile 24318: Call me Erwin

Above: Graham crackers are in ready supply on the surgery floor.

"ERWIN... JOHNNY...

ALMOST."

- My attending on a fellow medical student calling me by the wrong name.

Last year, during my Internal Medicine Rotation, I found myself eating a horrible breakfast a lot of mornings when arriving at the hospital.   However, it was the most easily accessible: potato chips and cups of juice (that in truth were only 10% juice) stared right at me in the resident's lounge.  It was a terrible combination. Well, during my Anesthesia Rotation, I've gotta say that I worked on it. I'm getting more nutritious by keeping my energy levels high through Graham crackers. These wonderfully available packets (above), kept me going through taking patient histories, inserting LMAs, and following through with patients in the post-op room.  Pretty potent for a small packet, I may say.

And here I am, after a full sixteen weeks of Surgery, currently in a 2 week break before hitting the road to Columbus.  As much as I'm not going to go into Surgery, the folks at St. Anthony have really taught me an appreciation for it (with or without the graham crackers).  I'm not going to forget how the masks and scrub uniforms on the nursing staff made people look completely different than when seeing them outside of the hospital.  That perhaps led to my last nickname, Erwin, when a fellow medical student couldn't come up with my name.

Erwin... It works.

However, my last four weeks in anesthesiology were quite interesting.  Originally, my perception of a day in the specialty consisted of placing some tubes and watching the patient as they fall asleep, then waking them up, and you're pretty much done for the day.  I ended up seeing their jobs are much more important then orignally thought, making me appreciate the rotation much more.  If you think about it, just a couple ounces of anesthesia, if placed into the wrong part of the body or if dosed wrongly could put the patient in danger.

I've talked about the "art of medicine" before from my perspective, as much more of a clinical thinking concept, but the "art of medicine" in Anesthesia I saw was one of procedure.  Many of the procedures, such as spinal or nerve blocks, or even the classic intubation require a lot of muscle memory and hours of practice.  Everything they do needs to be accurate and precise, or a lot of wrong could happen.  But it doesn't.  The doctors and nurses in the anesthesia department at St. Anthony were pros at their jobs.

And with that, I'm entering back into the realm of medicine, and taking a Cardiology elective at Grant Medical Center in Columbus, OH.  This is the start of the last big road trip I will make during my medical school career, and the start of the last three rotations ever.  My journey through medical school has been amazing so far, it can only get better toward the end.

Mile 23344: Shortie: A Steaming Summer

Above: I get double dared both on paper and in person on the surgical ward. This is the paper version.

I'M 8/10 IN USING MOTOR SOUNDS
TO KEEP BABIES HAPPY.

Well we jumped the 20000 mile mark just about a month ago, during surgery. However, studying for the big Step 2 CK exam which is coming up this month, so time has been limited to write. That doesn't mean that the writing is over. I finished my surgery rotation a month ago, took 4 weeks off to study, and right now am back in business with doing an anesthesia rotaiton here at Saint Anthony Hospital in Chicago, IL.

This is just a quick note to say I'm alive and I'm still counting miles (we're quite up there right now).

The summer has also brought some unexpected surprises.
- I'm now a Godfather to a beautiful baby boy, Joshua. I attended his baptism in June. He loves motor sounds. However, little did I know they only work on most babies. I learned that fact quite quickly at the baptism.
- Old Silver is now New Blue... Long story put short, my old 2002 Ford Focus needed to be retired, so a 2012 is now my new mode of transportation. However, my mile counting still sticks dead on the dot accurate mile for mile.
- It's match season, so applying to residencies is in play currently.

Another surprise: this summer has just been plain hot. And I'll be honest, with all this work to do, it's tough to get out there and enjoy it. However, I believe that work will pay off. And I certainly hope it does. More soon.

Mile 19314: Chasing the Smoke

Above: I really pride my hometown. It's quite a beauty, no? September 2010.

HERE...
HOLD IT!

Last week, my surgery partner and I are putting together a presentation for journal club on the Nissen Fundoplication we did earlier in the rotation. It was really cool to have an opportunity to present the case & the operation in front of the surgical nurses / assistants of the hospital. A really rad case the Nissen was, but I've been learning over the last few weeks that even the basic of the basic surgeries (I would assume that a surgeon would call them "easy cases") would teach someone going into primary care some of the easiest tricks up the sleeve for being a team player in the operating room.

I had written in one of my blog entries in Dominica, about the excellent communication I saw between nurses and the attending doctors. It's just awesome to see the voiceless transactions that occur here in the operating room at the hospital. But with the opportunity to scrub in with several surgeons, it's interesting to see how different attendings have different expectations on communication.

For some, they're pretty vocal. One of the surgeons I work with during Lapascopic procedures communicates well, and I kinda plug in extra judgment with my experience with him to get the camera angle right for him to use the "Bovie" with precision. (It's so weird, because you're acting as someone else's eyes). Some are a little less vocal, using one to three words to describe how to assist, such as the command that started this blog entry, "Here, Hold it!" Another one of the surgeons is a lot more silent, but with more experience with him, I'm able to figure out if he really wants me to chase the smoke or drain out the blood. And somehow, we get it to work.

In addition to learning more on how communication can go about in the operating room, I'll have to say that I'm happy that I was able to pull off my first suture in the OR... actually 2 small ones. We have an awesome set of nurses, attendings, and surgical assistants, and it's great to have an excellent support group (which I wasn't expecting in the first place from such a stressful environment in the OR). Also, as of this week, I'm learning how to throw in IVs... a couple of us get together around a table and basically spend the time to practice on ourselves, before going out in the "real world" and practicing on the patients. I'll admit, that it is touching to see that all of us are willing to risk potential hematomas or blown veins for each other's learning benefit.

This week, I started Orthopedic Clinic which I'll be doing for the next four weeks, and I'll update more on that in the next entry.

Mile 18039: Candid Camera

Above: Streaks of sky light up Covington, Ohio during a brisk March sunset.

I LOVE SEEING LESSONS COME
FULL-CIRCLE.

This week, I had an opportunity to guide the camera behind a laparascopic procedure. I enjoyed being behind it for once, pulling in and swiping across the abdomen to make sure the surgeon covered all the ground he needed to cover. When I was in Dominica, I had written about how surgeons and their assistants start to have this way of "hidden" communication. I've worked with one surgeon for the past week, and I'll admit the first time I assisted, it was like trying to teach a kid to bike without training wheels. Fortunately, I had a patient attending, so by the second time around, I started to get some of the gist of what the surgeon was going for.

For those of you not familiar with laparoscopy, the jist of it basically comes down to a fiber-optic camera (don't think of a lens-faced camera, but a camera in the a shape of a long-thin pole). Many surgical procedures in the abdomen in the past used to be conducted by cutting through the front part of the stomach wall, and when the surgery was over, a big scar would be left across the abdomen. Things are different with laparoscopy, a couple of port holes for instruments and the camera itself are poked in, leaving only a few small scars after surgery. It's much more cosmetically beneficial.

And here I was, keeping my eye on the plasma screens, on the scope, being the surgeon's eyes, and kinda like his brain (most of the time). And soon, the surgery was over. I was soon assisting in my first sutures, and I'll admit that its gonna take practice to get the art down of beating the "anesthesia clock." Basically, suturing up surgical openings is harder when the patient starts to breathe on their own and get active as they wake up from being asleep during the surgery. However, the thrill of jumping in to try things out is definitely there.

And, although my primary intention is still to go into primary care, I'll admit, Surgery so far has been a blast.

Mile 17935: Surgical Adventures of Dr. Shortcoat

Above: I was living "on the air" in Cincinnati. At the Cleopatra exhibit. March 2011.

SURGERY IS AN EXPERIENCE THAT CAN BE LEARNED

THROUGH EXPERIENCES.

On Monday, I began my 12 week adventure into Surgery. Operating room observation, follow-ups on patients on the floors, going to clinics to do more follow-ups and consults, and the list keeps going, but its something I'm looking forward to. I had talked about the operating room in Dominica when I first came onto the island, but I'm glad to be finally writing about it again.

This week, I experienced the longest of surgeries (at least according to one of the nurses) that I'll be experiencing. It was the Laparascopic Nissen Fundoplication procedure (basically wrapping a portion of the stomach around the esophagus as one of the treatments for GERD - layman, acid reflux - not responding to medication). Five hours standing, and assisting by basically handling instruments in an upright position for multiple hours. I'm a bit sore, admittedly, after holding up some of the instruments after a while. However, it felt good to scrub in and afterwards getting my first shot of real stitching after the surgery was over. I used to complain about my ability to scrub into a gown, but with this rotation, I feel I'm getting better.

The operation was rather interesting, as at a point during the operation, there were multiple plasma screens that I could look at, with one camera looking down the esophagus from the mouth and the laparascopic scope looking at the stomach from inside the abdomen. I'll have to say that doing surgery is sometimes like a concert... the lights are on, you have the best view when scrubbed in, and your attention is definitely on the person in the spotlight. Now I know where the term "Operating Theater" came from in Dominica.

My first real scrubbed in surgery was quite an experience. I'm looking forward to the next 12 weeks not just to experience what the profession can offer, but also to learn a few tricks from surgeons that may be applicable to my life in primary care (we still have to do procedures!). Over the next few weeks, I may be also reflecting a little bit more on my last roadtrip... as much as I'm missed Chicago, I'm now missing the road.

Dr. Shortcoat was a name I had earned from one of the nurses when I was in Decatur. More about how I got the name later.

Horn Honking

"YOU'RE IN... SCRUB UP!"

One of the best most memorable parts about driving to Roseau is the way that drivers love to use their horns on the road. I don’t know about you, but I am not afraid to use my horn whenever a driver passes me on the road back in the states, as the driver decides to almost slice the front bumper off my car with a not-so-slick pass on the expressway. However, in Dominica, although this can happen (Now, I’m thinking that being horn happy came as an after effect of the invention of the automobile), I’ve seen Dominican drivers use their horns for many reasons, such as:

1. It could be social: some bus drivers, when passing through the smaller towns, honk their horns and then wave to the people on the streets.

2. It could be out of courtesy: I’ve seen some bus drivers decide to use their horn to let someone know they could pass.

3. It could be for business: If I'm walking down the street by the bus depot in Roseau. Every single van's horn starts honking for me, to win me over in the bus-filling race that occurs there. (Although I'm flattered, I still pick the nicest looking van... I like the one with tiger-skinned upholstery. :P)

4. Most importantly... It sometimes could be attraction: like the Dominican driver that honks at women while he’s waiting to “pick them up” to take them back to Portsmouth... :D.

IT JUST SEEMS sometimes it seems that these customs are crazy to us in America. But what matters the people in Dominica have it work for them, and it works (yes, even purpose number 4... sometimes.)

How the heck does this relate to medicine?

Like I said in my last entry, one of my good colleagues, Alex, jumped in on a herniaplasty a few weeks ago in the Operating Room (actually, in Dominica its termed the Operating Theatre). Six of us med students were standing in our wide spectrum of scrubs - anywhere from "poop-like" brown (me) to a torquoise green (him). All of a sudden, the surgeon comes out and points at Alex and says, "You're in... scrub up!"

Bada bing and bada boom... He's ready to go. There he was standing in an operating room gown, with long latex gloves, pumping his hands in the air as if he was ready to take on a patient. And, he was in...

But there's a caveat... As soon as he had the handles on the tools, there was the doctor tapping Alex's hands on the forceps, and there my colleague was... caught completely off guard, semi-frozen. I really understand how he felt, because although the surgeon was telling him something, he had no idea what the surgeon meant by his friendly gesture. The surgeon then took my friends hands and placed them in the right position with the forceps around the suture in the right position. The doctor went over to the nurse, and also did the same tapping motion, and bam!, she was out there with the right suture string and placed it into the hands of the doctor, and I wondered how they figured it out so quickly...

It seemed that after many hours of working together, the nurse and the doctor somehow knew what every single gesture meant. Instead of taking precious seconds off of the clock to verbalize their intentions, those seconds went to use more efficiently ( a good case especially when circulation to a limb is cut off - precious seconds that could mean the difference between recovery to normal use of an arm or necessary amputation). That seems to be part to the art of medicine... finding ways to communicate make procedures more efficient and effective, using our creativity to its potential... and they're definitely not textbook, and even may seem crazy, by all means.

But remember: It got the job done.