WILTIMS #454-8: Big cuts, disappearing veins, and confirmed aspirations

Last week was a long one, and so is this post. Yay?

MondayILearned: Holding someone else's arm in tension is exhausting for more than 5 minutes. Also, a rib extraction through the axilla is pretty underwhelming when the rib is taken out in little pea-sized pieces. Also also, if you are holding/pulling someone's arm as long/hard as you can, you don't get a great view of the armpit through which they are doing a rib extraction.

Tuesday: I cut off a person's leg! Well, the attending cut some, and the resident sawed the bone but I used the scalpel to cut through the last couple inches of the patient's thigh to sever it from the body. That was surreal.

TuIL: When amputating a limb, it's a pretty quick and dirty affair up to and immediately after the main blood vessels have been closed up. You pick the line you are going to cut down and make deep clean cuts through the skin, fat, and muscle, but slow down when you know you're near a main artery or vein. These you clamp well before cutting or else risk considerable blood loss. Get down around the bone, clean off the tissue and whip out your handy-dandy electric bone saw. Make sure your med student is holding the distal limb as it is about to no longer be supported by the skeleton. Then keep on cutting. Angle out toward the dead limb near the end to create a flap of tissue with which to create your stump.

Wednesday: After the usual morning lectures, including a particularly schadenfreudenous M&M (morbidity and mortality), I spent the afternoon in the vascular surgery clinic. It was a little awkward because the resident I was shadowing for the day was essentially shadowing the attending, who happened to be the chairman of surgery for the whole hospital. Honestly though, I probably wasn't any more useless than I normally am in the OR.

Lovingly borrowed from UpToDate

WIL: Varicose veins can be removed instantly (it really looks like magic (needle-y magic?)) by injecting foamy soap into the veins which collapses and scars them closed. To make the foam, you use a funky looking right-angle connector pictured on the right.

Thursday: Instead of the normal OR, I spent this morning in the Cath Lab. This is the collection of specialized, minimally invasive procedure rooms where vascular procedures are done, like angioplasties (using a balloon to widen a constricted artery) or stent placements (expanding a mesh cylinder to keep the arteries open after the balloon is removed). These procedures can be done on the vessels of the heart, brain, or anywhere else all through a tiny tube inserted in the arm, leg, or neck.

ThIL: The cath lab has huge computer monitors to watch all the images taken by the doctors as they x-ray their way through the patient's vasculature. I'm not all that sad to see my vascular days behind me, but the added radiation doses I was getting from all these angiography procedures is an especially welcome loss.

Friday: This was my favorite day of the rotation so far (and it had little to do with surgery, unsurprisingly). As it was Match Day for the fourth year medical students who normally man the surgical intensive care unit (SICU), another third year and I decided to skip out on our normal teams (with their permission, of course) to help out the SICU team.

For some time now, I've been thinking that intensive care is the type of medicine I want to practice. But through this third year, as we are supposed to be learning about the different fields and making a decision, I've been hesitant to say that I want to be an intensivist because... well, how do I know? It's not like we are given much ICU exposure before 4th year. Every time I try to explain why I want to pursue this career, I feel like I'm just making things up that I've heard third hand or extrapolated from my limited pre-med school exposure to ICUs.

Today was great because I got to ask an ICU attending to pitch everything he loved about his profession to me. And every point he made confirmed points that I had been hoping to myself were true. The cerebral nature, bedside medicine, fun technology, teamwork, the best nurses, a focus on teaching... I'm sold. I also learned a new analogy for intensive care. Intensivists are to other doctors like relief pitchers are to starters in baseball; the primary physician takes their best shot at taking care of the patient on their own, but sometimes you need to bring in someone who specializes in getting out of a jam. It's not about wins, it's about saves.

Now, the bigger question: kids or adults?

FIL: There has been a big push in recent years in intensive care to get patients out of bed and moving around as soon as it is safe to do so. This is a big departure from the traditional strategy of strict bed-rest. The old idea was to conserve the patient's energy for healing, but the body doesn't work that way.