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.

WILTIMS #438-42 : Medicine wrap-up

Ugh. Eight weeks of medicine was exhausting. It both seemed like it took forever, and yet it wasn't nearly enough time to master everything for the mini-board (ya know, 'cause it's all of medicine). Good thing I will get a chance to catch my breath on my next rotation: surgery! Did I say catch my breath? I meant never sleep again! Ah well. Sorry for the super-crazy delayed catch-up post. I'd say that I will be returning to a more regular schedule, but... surgery.

TwoWeeksAgoIL: The common antibiotic bactrim increases the creatinine level (a common marker for kidney dysfunction) without damaging the kidneys. So don't panic about a patient's worsening renal status immediately after starting bactrim.

TwoThursdaysAgoIL: The wait time for liver transplants varies dramatically by region within the United States. In parts of the deep south, like Georgia, the wait time can be as little as a month and a half, but in New York or California, the same patient could be waiting seven to eight months.

A patient must have been ignorant to their alcohol problem to be approved for a liver transplant for alcohol-related liver failure. If they had already been warned about their drinking, and continued to drink anyways, then we can't trust them with a precious organ that they might voluntarily destroy again. Newly diagnosed alcoholics must go through a rigorous sobriety program to earn their new liver.

Quote of the Day: "To do the lobectomy, you essentially burn your way through the liver. I think of it as Sherman's march to the sea..."

TwoFridaysAgoIL: Pes anserinus bursitis is the painful irritation of the insertion of three upper leg muscles into the medial aspect of the tibia. The name "pes anserinus" literally translates from latin as "goose's foot" because of the shape of the three muscles joining looks like the toes (do birds have toes? [shrugs] somebody call a veterinarian!) of a goose.

TwoMondaysAgoIL: ...how to draw an ABG and, more importantly, how it feels as a patient to have an ABG drawn. My classmate and I decided to fill some downtime by stabbing each other!!! We had both drawn venous blood (which is the normal blood draw) and we had both seen ABGs (arterial blood gases) drawn, but neither of us had drawn ABGs before. Arterial blood draws are known to be substantially more painful than normal venous blood due to the beefier architecture of the vessels. We didn't want to practice this potentially painful technique on patients. So we borrowed some supplies and successively and successfully drew ABG samples from each other's forearms. It didn't hurt at all as it was being done, but then a steady deep ache set in afterward that stuck with me for a few hours. Not pleasant. I will never frivolously order that test.

TwoTuesdaysAgoIL: An idioventricular rhythm can look like a backwards Mobitz type II 2nd degree heart block. It amazes me sometimes that things like that don't sound like gibberish anymore. So, an idioventricular rhythm is a heart rhythm seen after heart surgery where the ventricles are beating on their own without the guidance of the atria. Totally opposite of the norm, the ventricles are actually beating faster than the atria. On EKG, this can look weird and result in the few "p-waves" from the atria creep closer and closer to the QRS complexes or the ventricles. In a Mobitz type II heart block, the p-waves progressively pull away from the QRS complexes.

WILTIMS #435-7: Experimenting

On Thursday, I was given a blessed reprieve from the torture of geriatric clinic so that I could present a poster at our school's Medical Student Research Forum. The poster was displaying an incredibly deceiving selection of information on the research that I helped gather as one of the leaders of the Cancer Education Awareness Program club. The data were accurate but of extremely narrow usefulness. I have trash-talked this research for so long, it was hard to sell it to reviewers and interested passersby with a straight face.

After having two reviewers hear us out, my presentation partner and I were fairly confident that we weren't winning any awards. Still, just to be sure, I stayed around through the big oral presentations to await the official losers' notice. The presentations were surprisingly good. The first guy's research had made national headlines when his team mapped the NYC subway biome and found plague and anthrax among the other more benign pathogens.

ThursdayIL: Actually, they don't think they found anthrax and plague. Nearly half of the life they found was unidentifiable by current techniques and it's more likely that the weird ones they did find were actually just as of yet unknown close relatives of those oddball bugs.

Friday, I was back at the hospital for my last day in geriatric clinic. The most interesting patient encounter of the day was actually due to a patient's daughter who had psychiatric problems of her own and yelled at our team for "experimenting" on her mildly demented father. All medications have potential adverse reactions and we can't (yet) predict which patients which react poorly. This patient may have had a reaction to a normally very safe medication we recently started... or the daughter may have altered his other psychiatric medications without consulting us. It was hard to tell who was actually "experimenting."

FridayIL: Frailty is an actual clinical diagnosis. Though it is not a true pathology, if a patient meets the (extremely specific) criteria then they statistically have significantly increased mortality from all causes.

Today I started with a new team on the inpatient wards, with whom I will slog out the remaining week and a half of this rotation (yikes!). Due to some weirdness with scheduling we practically had our whole previous team together for the day, so it was like a surprise reunion. I miss that team (sniff!).

TIL: Isothenuria is when the urine is osmotically similar to blood (neither concentrated nor dilute). This can be totally normal or a sign of renal failure depending on the broader clinical picture.

If a patient with a PMH (past medical history) of SCD (sickle cell disease) presents to the ER with symptoms that can be explained by a sickle cell crisis, check the reticulocyte count. The retic count represents the release of immature blood cells into the bloodstream and is a measure of hemolysis (blood cell death). The higher the count, the worse the hemolysis and the more severe the sickle cell crisis.

Pingueculae are a slight variation on pterygia, both lesions of the conjunctiva of the eye. Whereas a pterygium is seen more commonly on the nose-side of the eye and grow out toward the pupil, a pinguecula is usually seen on the ear-side of the eye and grows thicker, not moving in any direction.

WILTIMS #432-434: Untz untz untz... oh, not that kind of clubbing

MondayIL: Homans sign is a physical exam maneuver used to test for deep vein thrombosis (DVT). To perform it, you have the patient rest on their back while you support their knee. You then abruptly flex their ankle. If this elicits discomfort, it is positive for... actually probably nothing. This sign is a terrible predictor of DVT and may even be dangerous to perform. Don't use this test.

Every once in a while I learn something that I realize I should have learned ages ago. Unfortunately I usually learn these facts in an awkwardly public setting like in front of attending or patient. Today's example is about clubbing. Clubbing is when the tips of one's fingers swell and the fingernails curve (making the fingers look like little clubs, hence "clubbing"). I therefore thought that dramatically curved fingernails were indicative of early-stage clubbing. Nope. Not a thing. People can just have curved nails.

The way you actually tell if there is clubbing is by looking at the angle made by the tip of the nail, the root of the nail and the first knuckle. If it is concave, it's normal. If it's flat then there is mild clubbing. If its convex (the nail bed bends out between the knuckle and nail tip) then there is severe clubbing. We still don't know what causes clubbing, just that it is correlated with a whole bunch of serious disease processes.

TuesdayIL: Gadolinium contrast (the stuff used in MRIs to make body-stuff more visible) is cleared from the blood much more slowly in patients with chronic kidney disease. This can cause nephrogenic systemic fibrosis, a disease that sounds really vague, but is actually only caused by gadolinium exposure.

Autosomal dominant polycystic kidney disease (ADPKD) is caused by a defective APOL1 gene. This allele is very prevalent in the black population, much like the sickle cell allele, and it's thought that this parallel is due to a similar reasons. Whereas sickle cell heterozygotes (people who only have one copy of the defective gene) are thought to be protected from malaria, APOL1 seems to protect from a different parasitic disease called trypanosomiasis.

We have no good treatment for ADPKD. We can essentially use dialysis to bide time until a kidney transplant can be done. An interesting issue can arise when a family member wants to donate a kidney. Since the disease is inherited, there is a not-insignificant chance that the family member also has ADPKD and will need their extra kidney for as long as it is healthy. So to attempt to donate, the family member needs to consent to finding out that not only can they no donate, but that they may be soon heading for the same fate.

WednesdayIL: Dementia can cause increased variations in an elderly patient's sleep cycle. There are normal age-related changes, such as going to bed earlier, waking up earlier, sleeping lighter, waking up more often, etc. Patients with dementia frequently have worse sleep disturbances including a shift away from the restful REM sleep.

WILTIMS #429-31: The future! ...and bladders

Wednesday was another class meeting. It always seems like they manage to take a full day to get across maybe a half-hour of new information and re-hash maybe another hour of old information. I'm still not sure where all the time goes.

WednesdayIL: Fourth year is going to be pretty chill (assuming I survive to see it). We learned about the flexibility and inflexibility of our schedules. Depending on what we want to do for residency, there are certain tracks we have to take that consist of a sub-internship (in either medicine, surgery, or pediatrics) and two of three core clerkships (emergency medicine, intensive care, and radiology). We then fill up our schedule with electives according to unnecessarily complicated rules regarding maintaining a balance of clinical vs. non-clinical, face-to-face vs. online, and school affiliate vs. away rotations. Of course, each course is only offered during certain of the ten month-long blocks. It makes me long for the undergrad days of looking through course catalogues and mapping out graduation requirements. Hmmm... I guess that was stupidly complicated too.

Thursday there weren't many patients in the normal geriatric clinic area so my classmate and I shadowed a geriatric urologist for the morning. It was a fun departure from our usual experience.

ThursdayIL: The optimal walker height can be approximated by the level of the wrist when the patient has their arms at their sides. This is lower than most people would intuitively guess, but has been shown to promote the best posture and gait.

Urodynamic studies look at how the bladder handles urine. It works by inserting one pressure-sensing catheter into the bladder and another into the rectum. You then have the patient consume a bunch of fluids and monitor the pressures as the bladder fills. This lets you see if the bladder is able to fill and remain relaxed. Then you have the patient void. This lets you see if the patient uses the bladder muscles or abdominal muscles to urinate. Also you can see if the bladder is able to fully empty. The upshot of all this is by sticking two tubes in uncomfortable places you can learn a lot about someone's bladder function.

TIL: Acute glaucoma (the rapid rise in the pressure of the fluid in the eye) can cause conjunctivitis (redness of the normally white part of the eye). So don't assume that someone with a red eye simply has an infection because if it is glaucoma, they could go blind in that eye without treatment.

WILTIMS #428: Needing Beers to get through geriatrics

Last Tuesday I had a really good day. Today was less so. As much of the miserableness involved people who control my grade and my little blog is technically a public forum, I will just leave it at that.

This week I started my two week stay in the hospital's geriatric clinic. Not my particular cup of tea, but it should be survivable for the short duration. I had an interesting experience today looking back through the chart of a very elderly patient. Currently about 85 years old with several serious health conditions, she needed of a good deal of assistance with her daily activities. As with any patient, I read-up on her recent admissions and notes from the doctors who had taken care of her.  I learned a good deal about her medical history, but very little about her personal life - her story.

So then I dug into the social workers' notes. These provide great details about a person's living situation. I was surprised to find electronic records going back over ten years to when the patient was about 70 years old. And suddenly I realized that I had the documented history of one woman's journey into old age and frailty. each successive note showed how a heart condition or fall changed what she was able to do and how she was able to live.

I realize that the sorts of records have always existed in some form, but with the adoption of electronic medical records, it will become so much easier to essentially read the (very dryly written) story of someone's life through their interactions with the medical field.

TIL: AICD stands for artificial internal cardioverter/defibrillator.

The Beers Criteria is a list of drugs that should be used cautiously in the geriatric population. When it was first created in 1991 by Dr. Beers, it was a very simple, one-page tool to help prevent needlessly dangerous prescriptions. The most recent version is a dozen pages of very specific guidelines. Not sure if that's really serving the same purpose anymore...

While researching the Beers criteria, I learned what a non-anti-infective medication is. I'll let you read that one more time: non-anti-infective medication. What? Despite how it might seem, the negatives do not cancel out, which would make these simply infective medications. Actually these are medications other than those used to kill or weaken infectious pathogens such a bacteria, viruses, fungi, and parasites.

Endoscopic ultrasound is a nice alternative to MRCP for imaging choledocolithiasis.

Whereas gallbladder pain radiates to the chest and shoulder, the common bile duct radiates to the flank and back.

WILTIMS #427: IM didactic day #2

Today was a fairly dry day of lectures back up at campus (check out yesterday's post for a week's worth of juicier clinical fare). We started with dermatology, then a miserable lecture on HIV, some antibiotic practice and EKG interpretation. After a far too brief lunch, we came back for a stuffy lecture on congestive heart failure by our stuffy chairman of medicine and then we ended with a lecture on palliative care and pain management.

TIL: Urticaria pigmentosa, or maculopapular cutaneous mastocytosis, is a weird condition where mast cells accumulate in blobs on the skin. These immune cells release histamine, one of the chemicals that makes you itchy. So if you poke one of these spots on their skin, within a few minutes a big itchy red wheal will form.

Derm lightning round!

• nummular: round; as in nummus, Latin for "coin"
• arciform: arc forms
• serpiginous: snake-like
• ichthyotic: fish-scale-esque
• koebnerization: spreading a lesion by patient interaction (e.g. a rash that spreads to the areas you scratch)

Ways to be wrong 95% of the time, but scary-awesome the other 5%: If someone has a rash around their mouth, ask if they like to eat mangos. If no, then delicately ask if they suck their thumb. Both of these are reasonably common explanations for a perioral rash and you'll look like a mind reader if you call out a(n unknowingly allergic) mango enthusiast or adult thumb-sucker.