CT stuff, cont.

I just shattered the 80 hour work week—actual number now is 90. Yesterday I had to round/call consults/pull chest tubes from 6:00 to noon, then came home thinking I would have the afternoon off, go to bed early, and have all day Sunday to relax and do housework. Ha. I went back in at 3:00 for an emergent bypass—the fellow had to work on harvesting the saphenous vein from the leg, so I actually got to first assist the surgeon for a while—much more fun than just watching. When the fellow was done, I got to close a lot of the skin and bandage the leg. The bypass went by very quickly (4-5 hours) for a bypass, and I was excited to still get home and be able to get enough sleep that I could go to church in the morning. Naturally, it was about that moment that the cath lab called and said that yet another man with crushing chest pain was just discovered to have 90% occlusion of his LAD coronary artery. To make a long story short, I left the hospital at 1:30am. It actually was very interesting though as this latter surgery was done off bypass with the heart beating—up til then I had only seen bypasses with the heart stopped. It makes for a much faster surgery. One thing that I have learned on this rotation that I was clueless about before is the closing times of the fast food restaurants where I live. Would you believe Burger King is the only one open til 2:00?

All in all, this has been a pretty good month. The surgeries I have seen are by far the most exciting and interesting surgeries I have ever seen (in my admittedly very limited experience). It is amazing to just see a beating human heart, let alone touch it and work on it. The surgeries are literally life saving, adding on years to someone’s life expectancy with just hours of labor. However, the lifestyle is horrible—I thought my general surgery month took a lot of time, compared to this it’s nothing. Once I got used to it, being at the hospital 70-90 hours a week is surprisingly doable, but you have to be able to give up every other commitment in your life. I can’t imagine being married, much less having kids on this rotation. It was not a surprise for me to find out that CT surgeons have a 90% divorce rate, a statistic well reflected by the CT surgeons at my school. Several of them are already on their third wife and their kids completely resent them. So, while I am very glad to have had this experience, I think I can safely say that CT surgery is not going to be an option for me.

CT stuff

I have just officially worked my first 80 hour work week. Monday is usually the day when we have nothing to do aside from working in the hospital—no lectures, teaching rounds, etc., so I went ahead and just wore scrubs instead of professional dress. Big mistake. At about 6:30 I overheard another student telling her resident that we had OSCEs (interviewing fake patients) that morning. I and the other student on CT surgery had totally forgotten about it. I ended up having to drive all the way home (30 minutes in good traffic) to change and all the way back, getting to the test site with about five minutes to spare. A very annoying way to start the morning. Tuesday I saw a triple bypass in a 45 year old man. That evening the clerkship director had dinner at his house for all the students on surgery. His wife is a “3/4 time” family practice physician and they have four very energetic children all under the age of nine. The oldest child was having fun talking to all the medical students about electrons and hormones.

Wednesday was lecture. Like last week, I was hoping to leave after lecture and go to the library and study and finish writing up H&Ps. Also like last week, these hopes were dashed. I ended up having to go into the tail end of a (you guessed it!) bypass. I left at about 8:00, so I did manage to make it to Bible study. Then I had to stay up til midnight finishing the H&Ps.

Thursday was my day to go over to Children’s hospital to watch a pediatric surgery. It was a several month old child with pentalogy of cantrell, a very rare congenital disorder. The child essentially had an opening between the two main chambers of her heart which needed to be closed. It was really quite amazing—her heart was about the size of a golf ball. The surgeon sewed in a patch to fix the defect. Unfortunately, when he tried to take her off bypass, her heart didn’t want to start again. They got an echo and found that the middle part of the patch was buckling and blocking her aorta. The surgeon opened the heart again, finnagled with it, then tried to take her off bypass. Again, no success. He ended up having to take the patch out. They put her on ECMO, a form of cardiopulmonary bypass, and are going to let her rest for a couple of days before trying anything else. I left the case at 1:30 am, thus setting a new record for the longest surgery I have ever been in: 16 hours. Unfortunately I was wearing contacts so I had to drive home to take them out, sleep two hours, then go back. Had I known I would be there so late I could have just worn glasses and slept at the hospital which would have been a lot easier. At about 9:00pm I decided that I am just not meant to be able to study for the exam on Tuesday.

Friday morning I saw a consult, a woman with a newly found lung mass, had the cup of coffee I had been dreaming about since Thursday morning, and saw an esophagectomy. The surgeon removed the esophagus (the patient had Barrett esophagus which strongly predisposed her to esophageal cancer), then formed a tube out of the stomach and brought it up through her chest and attached it to the remaining cranial portion of her esophagus….I just got paged—I have to go back in for an emergent heart procedure—I guess I’m really not meant to study for the exam on Tuesday—to be continued, likely with an explanation of why I will never be a cardiac surgeon...

Rounds

It hit me. I went to bed at ten, when I woke up I thought it was probably about nine—actually it was 1:30pm. That pretty much destroyed any chance I had of doing something productive. I did manage to type up a couple of H&Ps, eat dinner, then go to bed at ten. Naturally, since I had just gotten 15 hours of sleep I stayed awake for several hours, which would have been fine if I didn’t have to wake up this morning at 4:45. I do feel better now with 16oz of coffee in me.

This morning I saw 6 patients in just a little over an hour. Since the intern has been avoiding the obnoxious patient I have previously described she made sure he was one of the ones I had to see. Surprisingly I managed to keep my time talking to him at less than three minutes, and was starting to be less inclined to dislike him. That changed when we rounded with the attending and fellow and he went into gory detail about how his wife has a phobia of touching him, refused to wash his back this morning after washing his hair, and then described the most private matters of his personal life that I really did not need or desire to hear. Somehow he worked into the conversation that he wears $1500 suits when he goes out so he can attract women’s attention, that his wife doesn’t understand that, and that he dresses better, is taller, and is more handsome than any of us (the attending, the fellow, and me). I think he has some narcissistic tendencies. After we left his room, even the attending (who enjoys telling crass/dirty jokes in the OR) said he felt like taking a shower. We were going to discharge him, but his blood cultures grew bacteria so now we have to monitor him for several days.

Transplant

This week has been rather busy. I can’t really recall off hand what went on Monday and Tuesday, but Wednesday was lecture from 6:30-6:30. I had to present the tracheal stenosis patient to my classmates—typically one presents the patient’s chief complaint and students have to ask questions about the history and try to come up with a differential diagnosis. Three other students went before me, and each one took more than a half hour to present, which made me a bit nervous because I didn’t think I could stretch my presentation out past 15 minutes. Thankfully by the time it was my turn we only had about twenty five minutes of class left so the doctor heading the discussion told me just to breeze through, so all went well. I decided to skip the last lecture since 11 hours was quite enough for me, and went back to the workroom thinking that I would check in and be told to go home, then I could go to school, stop by the meet the surgeons cocktail party that was going on (I probably would have just ended up standing by the hors'douvres table cramming food down my mouth avoiding social contact anyway), then go to the library, study (which I haven’t had time for yet this week), change, and go to Bible study (this night each of us was going to share favorite passages—my choices were Job 19:23-27 and Rom 8:18-39). Unfortunately, when I got back I was told that a heart bypass which had started in the morning was still going so I had to scrub in. It ended up being the CABG that would not die. The patient, showing flagrant disregard for my plans, refused to stop bleeding (apparently he had an anti-phospholipid syndrome that messed with his clotting factors). As the hours ticked by, my plans became increasingly shorter. I managed to hang on to the hope that I would at least make it to the tail end of Bible study, but that hope, like so many, at last died a horrible death. The CABG went on til about 11:00pm, the doctor had been pretty calm the whole time, but afterwards he told me he thought that the patient was going to die on the table. I wrote the op note and went home for the three and a half precious hours of sleep I would get before coming back to the hospital.

Yesterday I went in, saw several patients, then scrubbed in to two cases. The first was a lung tumor removal, the second was a left lung removal. The fellow had to go to clinic, so I first assisted the surgeon (ie I held retractors). I got a very good view though, it was quite interesting. And between cases, I managed to go to the free drug rep lunch hidden back in the general surgery offices. After the lung removal came the exciting part. A heart in Colorado had just become available for transplant, and was a match to a man in the city in which I live. One of the surgeons had flown out early in the afternoon, and was on his way back with it. I was not on call so I could have gone home, but since this was possibly a once-in-a-lifetime opportunity I stayed. It was definitely worth staying for. Two surgeons worked together to get the patient ready—they opened him up while the donor heart was still in the air so that he would be ready for transplant as soon as the heart arrived. At 8:30 a group of people walked into the OR wheeling an ice chest. The surgeons put the patient on heart lung bypass (a machine that keeps blood circulating through the body when the heart and lungs are not functioning), cut out the patient’s heart, and tossed it, still beating, into a bowl. It was huge from chronic heart failure. The donor heart was much smaller. They prepared it, and sewed it in over about an hour’s time. Then, they monitored it, and finally closed at 2:00am. The other student and I left at about 2:30. Since we had to be back at 6:00, I considered not even going to bed because I was afraid if I did I would not be able to get up. I was too tired though, so I decided to take an hour nap before showering and going back. Although I have no memory of this, I somehow ended up getting out of bed, turning my cell phone alarm off, and getting back into bed, because when I woke up (I even left my bedside light on so I wouldn’t fall too deeply asleep) it was 6:15. Since I live a half hour away from the hospital, I had to page my intern and tell her I would be late, fortunately she was all right with it.

I finally got to the hospital at 7:00, and just had to see one really repulsive and manipulative patient. Naturally he was the type who likes to hear himself talk, and since I am too nice to be rude (I need to work on that) I had to sit (by his order) and listen for a good long while to his theory about constipation, his self-remedy, and what we as compassionate hospital staff should do about it—no more details needed. He was really freakish, he would make horribly suggestive comments to every female who walked by (he’s 62 by the way); if I were one of them I would have walked in and knocked him out. Plus he referred to himself in the third person. But, he does have serious physical problems and still needs good care regardless of his personality.

I was hoping that we would be allowed to leave early, but this was not to be. We had to round and do floor work until 4:00. Now I need to go to bed since I have had 6 hours of sleep in the last 60 hours (I am still surprisingly energetic, I am sure it is all going to hit me soon…)

More CTS

73 hours at the hospital this week. Last night I thought that I would probably break 80, but fortunately that was not necessary. This week I have seen several bypasses and an aortic valve replacement as far as heart surgeries go. The aortic valve replacement surgery was a little dicey, when the surgeons tried to take the patient off of the heart/lung bypass machine (keeps the blood circulating while the heart is stopped) his right ventricle did not function properly; the only reason they could come up with was that they might have accidentally messed up the right coronary artery. They did a bypass on that, and since they were so busy I got to sew up the patient’s leg (they had removed his saphenous vein for the graft). It took a while, but it didn’t look too bad when I was done. Finally we took the patient to the ICU, where he proceeded to code. The surgeon at first thought he wouldn’t last the night, but he eventually stabilized and was doing better the next morning.

As far as thoracic cases go, I watched a joint otolaryngology/cardiothoracic surgery on a man with a narrowed portion of his trachea. They had to open up the neck, and basically cut out a portion of the trachea then sew the two ends together. At the end they took the most massive suture needles I have ever seen, and sewed his chin to his chest to make sure that the patient wouldn’t move his neck the wrong way and kill himself. The sutures have to stay in for a week, seeing them made me want to hold my chin really close to my chest for the rest of the day. Yesterday the other student went into a bypass, and I saw two very quick procedures, a sympathectomy and an esophageal dilatation. The sympathectomy was the removal of a couple ganglia in the sympathetic chain to treat a woman’s hyperhidrosis—essentially she has had really sweaty hands, armpits, and feet since she was a child, and it has been embarrassing as well as a nuisance particularly when she has to handle paper at her job. As soon as the surgery was over she was cured. When I saw her this morning she was talking about what a miracle it was.

The rest of yesterday was very relaxed. One of the patients I saw in the morning wanted to set me up with her grand-daughter (not surprising, I'm quite a catch:) who is apparently a first year at another medical school. I rounded on patients with the attending, pulled a chest tube, and (!) ate lunch for the first time in a week. That, however, was a trade-off for not getting dinner. At about five, when I was getting geared up to leave, a man came into the ER with a ruptured esophagus. He went to the OR at about six, and I stayed to watch. When esophaguses (esophagi?) rupture, one tries to repair them in the first 12-24 hours. However, this man had had symptoms for more than a week, and was thus very infected. The ER put a chest tube in, and (I did not go down) you could smell him throughout the entire ER. In the OR, they opened his chest, and his left lung and chest wall were completely covered in white gunk. The surgeons spent two hours peeling it off. The esophagus was a mess, and was impossible to repair, particularly with the infection, so they stapled his stomach closed, opened his neck, pulled out his esophagus through the hole (the distal end was very nasty looking), cut it, and sewed the remaining end to his skin to form a “spit fistula” through which his saliva can drain into a bag. They then put a tube into his small intestine to feed him. He will have to remain like this for the next 6 months which will allow him to heal up. Then, they will re-open him, make a tube out of a portion of the stomach, and attach it to what is left of the esophagus which will allow him to eat. The reason for his rupture is because he is an alcoholic, now anything he takes by mouth will immediately drain into his ostomy bag. I wonder if he will stop drinking, or if he will put the alcohol directly into his intestine tube? The surgery finally ended at 11:30, and I got to come home and sleep for 3.5 hours before going back this morning. I wrote notes on four patients, then my intern told me to go home which I gladly obeyed. There is bypass scheduled today, and I was very afraid that I would have to scrub in on it which would have meant I would be there til 5 or 6 pm. I’m happy with 8am:). Now I can write up a couple H&Ps that are due, put together the presentation I have to give on Wednesday (I’m presenting the tracheal stenosis patient because he has some very nice CT images), and actually study for the exam that almost half my grade will be based on. Sad story of the week: I set my VCR to tape Lost this week, but when I got home it never started recording:(. Now I’m going to have to try watching it on the ABC webpage and put up with the constant freezing and re-starting of the images.

CTS

This week has been my first week of cardiothoracic surgery. It is quite a bit more laid back than I was expecting it to be. The team is set up a bit differently than what I am used to. The only resident is an intern. There are five attendings, two or three fellows, and then several nurse practitioners and PAs. The NPs and PAs manage the basic components of patient care in the hospital, except on the weekend when the intern takes over.

Monday was orientation; afterwards the other student and I saw the last half of a lung lobectomy (removal of a lobe of the lung) for lung cancer. Tuesday we had teaching rounds in the morning which made us miss the one surgery scheduled. In the afternoon, we saw a consult patient. We went to her room and looked through her chart, then as we were about to knock on the door it suddenly opened and the patient, all dressed up in coat and gloves was about to walk out. She informed us that she was going to go to the grocery store. We talked her into letting us talk to her first—she was a very pleasant lady, but didn’t tell us anything relevant as to why she was in the hospital. We finally left, and I mentioned to the front desk clerk that she was about to go to the grocery store. They got the nurse and put a guard at the door.

Wednesday was lecture all day. Thursday the other student scrubbed in for a triple bypass with aortic and mitral valve replacements, and I went to clinic. Clinic was very painful, although I did learn a lot and saw a wide variety of problems. The pain was largely because for the most part I just shadowed the doctor and nurse practitioner, and also because there was no lunch break so I didn’t eat from 5:30am til 5:00pm. Thursday morning I experienced what was quite possibly the most awkward situation of my medical career. I went to round on a young lady I had not seen before (on this service students often round on different patients every day which means that in fifteen minutes we have to read the chart and figure out why the patient is there, go see the patient, and then write a note including a plan). She had had cancer as a child, then was found to have some suspicious lesions on a chest x-ray recently, so she had to have the lumps removed. I’m pretty sure they were negative for cancer. I went into the room and introduced myself, then she asked if I knew a certain person who happens to be another third year student in my class. I said yes, and she told me that he is her husband. Then, all of the sudden, he walked into the room to see her. It was horribly uncomfortable, what on earth do you say to someone you don’t know very well whose wife just came close to being diagnosed with a fatal disease in her early twenties and you didn’t even realize he was married, much less in this situation? What makes it worse is that I can’t even share this story with my friends at school because it involves someone we are all familiar with.

Friday the four students and I went to an hour and a half long pimping (doctors asking students questions for the purpose of teaching, a practice often abused in the past by some to humiliate students) session at the VA with a cardiothoracic surgeon which was rather painful but very helpful. I found it impressive that he was taking an hour and a half out of his day to help third year students. And he brought cookies, which ended up being my last caloric intake until 8:00pm. When we got back to the main hospital, I went to a CABG x2 (double bypass). It was about a five hour long surgery but very interesting. Very amazing to be looking at a beating human heart. My role was basically as an observer until the end when I helped the fellow wire the sternum back together and sew up the incision. After, we rounded on the patients, then the intern and I went to see how the operation the other student was involved in, an esophagus removal on a 420 lb man, was going. The intern really wanted to go home, so she was hoping to make an appearance then leave, but the attending said as soon as she walked in that she could scrub if she would like, so of course she couldn’t tell him that she wanted to go home. The other student, who has no interest in surgery whatsoever, looked like she was ready to die. The case ended in an hour, and I was at last able to go home and watch the new episode of “Lost” which I had taped two days before. It is getting very interesting.