WILTIMS #443-8: Surgery

So it begins. This rotation is always built up as the big beast of third year. The hours are the worst, the residents/attendings are some of the worst (I'm looking at you OBGYN), and the miniboard is essentially testing you on all of medicine again plus some stuff on managing surgical patients. Wednesday I got up at 3am, to leave the house by 4:15, to get to the hospital by 5:15, to collect the vital signs on all of the patients for the team by 6am, when we start rounds. From 7-8 today was M&M - not tasty candy, but the weekly Mortality and Morbidity conference. Here surgeons present mistakes that happened this week so that everyone can learn from them. 8-9 was a grand rounds presentation on aortic valve replacements. 9-10 was a lecture on pancreatitis and some case presentations.

At this point, one of my classmates and I realized that we were already exhausted and we'd be lucky if we got to go home in another 7 hours. Thursday, after a case went far longer than expected, I actually left at 7pm - nearly 14 hours after I sleepily stumbled into the hospital that morning. I can't complain though because a classmate left that night at 9pm.

Eight weeks. EIGHT WEEKS. Eight. Eight weeks. Oh, and one of those weeks is night shifts. Plus two weekend shifts.

Survival is the goal here.

MondayIL: Low blood pressure in pregnant woman? Tilt them a little onto their right side to relieve pressure from the vena cava.

Phrase of the day: "Not dead until warm and dead." If someone is brought in with severe hypothermia and no signs of life, you must warm the person before you can pronounce them dead. Once you warm them, there is a chance that their extremely suppressed vital signs may come back. If not, then they're actually dead.

TuesdayIL: Vascular surgeons can build you a new aorta inside your crappy one, so long as they reroute blood to all the arteries that normally branch off of the aorta. Do not think this is some Bionic Man stuff; this is the absolute last resort and will probably only buy you a few more years before something catastrophic happens. The diagram on the right was drawn by our chief resident to explain what the plan was to the whole team.

WednesdayIL: Since acute pancreatitis is a clinical diagnosis (i.e. there is no test or scan that needs to be done to officially diagnose it), there is actually no need to do a CT scan until around 72 hours after presentation. At that point, you can tell the difference between inflammation and necrosis which can help steer management of the condition.

ThursdayIL: If you are inserting a bypass from an artery in the groin all the way to an artery in the lower leg, you need to cut out a vein too. You attach the vein (upside down so that the vein valves don't stop the blood flow) to the lower end of the artificial graft tubing. This provides some "give" to what would otherwise be a very rigid connection as veins are much more compliant (stretchier) than both plastic and arteries.

FridayIL: As a general rule, if a person has big, soggy looking legs, it's a problem with the veins. If they have tiny atrophic legs, it's a problem with the arteries. This makes sense. If your veins can't drain the blood out of the legs, the blood pools. If the arteries can't get blood to the legs, they waste away.

from Wikipedia

YesterdayIL: The IVC filters that we insert into the vena cava to catch blood clots are (1) placed very quickly in a 5 minute procedure, (2) only capable of catching pretty large clots - about the size of your pinky fingernail, and relatedly (3) only meant to stop clots that would kill you, not catch 'em all.

Looking for more? Check-out my previous post wrapping up internal medicine.