Poop

Luckily my friend's dad is feeling a bit better... kicked out of the hospital. No more obsession with flatus. Now family is obsessed with poops.

Abdominal surgery

My friend's father had emergency bowel surgery this past weekend, so I've received many surgical type questions which I'm marginally qualified to answer. In any case I'm finding it amusing with how my attention is being taken to his gastrointestinal tract, specifically the ability to pass gas. Hope he's feeling better soon.

Mini Mall

Ever heard of grand mal seizures? It's the type of seizures most think about as seizures, with unconsciousness and violent jerking movements.

I'm in clinic today. On her history form she has written "mini mall seizures".

I usually shop at mini-malls, but I think she means petit-mal seizures. These are also known as absence seizures and not associated with jerking motions.

Poor historian

I'm in clinic again... the bane of the non-pain anesthesiologist. A 60-some year old woman is here for surgery. She's had a history of heart failure. (Her heart is damaged so it doesn't pump very efficiently) She's a terrible historian.

Now for non-medical types, this doesn't mean she didn't know that Washington crossed the Delaware. It means that she's a terrible reporter of her own medical history. For different patients it means different things. To some it means that they can't remember what they've had done in the past or what medical conditions they have. To others it means that they ramble on so much it's hard to separate the medical information from random stories about their puppy. And my favorite group is the group where they're so vague about things that it takes 14 follow-up questions to get what you want from them.

"So how bad has your heart failure been" (Looking at the chart with 6 heart failure meds on.)
"Oh I don't really have heart failure"
"Hmm... really. Can you climb a flight of stairs?" (I don't care if she has stairs in her house, I just want to know if she can tolerate minor exercise)
"Oh I don't really climb stairs with my back and all" (Meaning she can't do it)
"How about walking, how far can you walk?" (Easier than stairs)
"Oh not far..."
"Do you ever get chest pain or shortness of breath?"
"Well not really.... well only if I walk too far." (Meaning yes all the time)
(inside) *sigh*

So I look again through the notes. There's a note from the Primary care provider (PCP) "Will stress before surgery." Now someone there has a good idea. Good to know if this lack of function is due to her heart or her back before we possibly kill her in the operating room.

I flip to the studies. I see a non-stress echocardiogram (essentially a heart ultrasound picture) from five months ago showing diastolic dysfunction. And a stress echocardiogram (same pictures, but while giving a chemical to stress the heart) from last month. "Indeterminate. Study cancelled due to hypertensive response." So they cancelled the stress in the middle because her blood pressure got too high. Fine. What did they do about that. I see another non-stress echocardiogram from two weeks ago. Hmm.... curious. So the stress was unable to be done, so they repeated a test that DIDN'T stress the heart, and had results we ALREADY knew about.

So it's six days til her surgery, I have a patient with known heart failure, maybe shortness of breath, maybe chest pain, two non-stress tests, and an indeterminate stress test. Someone also has decided before me that a stress would be a good idea, but never really followed through. So I have six days (including two weekend days) to get her stressed (a different type of stress test) or cancel the surgery. Luckily the ladies out front (the wonderful office staff) are able to get her scheduled for early next week. I cross my fingers and let her go.

The intern asks me what happens if the stress is positive next week. Good question. If it's negative, then I'm just a worry-wort and paranoid about nothing but she should get her back fixed. If not, then they need to evaluate her to see if anything can be done to optimize her heart before her elective surgery. This may mean changing her medications, or performing a heart catheterization, or more.

Did I tell you I love clinic?

Study Says Chatty Doctors Forget Patients

Study Says Chatty Doctors Forget Patients

Funny... except for the patients. Published in the Archives of Internal Medicine via the New York Times

Playing Doctor

I got to play "real" doctor this weekend.

Not that an anesthesiologist isn't a real doctor, but it's not immediately what comes to mind when you say doctor.

My friend volunteers at a free county medical clinic run by medical students some weekends. The medical students see patients and are staffed by physicians from the community. They were running short of physicians this week so I offered my services.

It was a little different than my usual Saturday morning, but a little fun nonetheless. I only had to ask a few questions to the "real" doctors.

A lot of me saying to medical students "just warning you... I'm an anesthesiologist."

Staffing shortage

This week we opened a new building... brand new operating rooms, new offices, etc. beautiful place. Still some growing pains as we are somewhat short staffed.

Yesterday, we had an urgent case to start. No residents or CRNAs were available since it was a lecture day and the available people were giving breaks so other people could go to their lectures.

Anyway they had an available OR, and I myself was giving lunch breaks....

So I just went ahead a did the case myself.

I know this doesn't sound too strange to most of you. It's probably the norm in most places. But being at an academic institution I haven't done a case by myself, well ever. In the few years I've been staffing, I always work with a resident or CRNA. Before then I was a resident so I worked with a faculty member supervising me.

It's nice knowing you have your stuff together well enough that you can do a case by yourself at a moments notice.

Yay me.

Preop Hijinks

So I'm in clinic today and I'm talking to a patient about his health problems for some surgery or another. All of a sudden he stands up, unbuckles his belt buckle, unzips his pants and starts tucking his shirt in.

Now I've done this before too, but usually it's in my bedroom before I go to work or if I'm in the bathroom or if I'm alone somewhere with no hope of someone walking in.

Weird and unsettling.

I just acted like nothing was happening and averted my gaze.

Condolences

As you no doubt have heard by now. A plane with an organ transplant team crashed into Lake Michigan on Monday. All six aboard were lost.

Condolences to the families of the two doctors, two organ donation specialists, and two pilots.

They perished in the quest to save the life of another.

Tragedy

I don't really want to talk about it now but do me a favor.

Go home, kiss your wife or husband, boyfriend or girlfriend, hug your children.
You never know when it's the last time.

More later... maybe

Tuberculosis

Everyone knows the name of Andrew Speaker. If you don't he's the person carrying the multidrug resistant tuberculosis(TB) stain all over the world.

First, Tuberculosis. It's a difficult disease to treat... months of antibiotics are required in most instances, and usually more than one type of antibiotic. Because people generally feel fine when they have this diagnosis they often quit taking the medication. This leads to more drug resistance.

I find a few things very funny about the case.

1. He's a personal injury lawyer. If someone else had done this I bet he'd be on TV advertising for people to call him to get their "rightful settlement"

2. His new father-in-law... works for the Centers for Disease Control. Speciality -- tuberculosis. You can't make this stuff up.

3. His name came up when he crossed the border from Canada. "including instructions to hold the traveler, don a protective mask in dealing with him, and telephone health authorities." The border inspector ignored these warnings because they appeared discretionary and the man appeared healthy. Good to know the system works. Good thing he's wasn't a terrorist. I imagine if he had been of middle eastern ethnicity he would have been face down handcuffed in a ditch in twelve seconds.

I'll give the guy some credit. He's probably not extremely infective from what I know about TB. He wasn't coughing, he probably didn't have an acute infection. He also picked it up somewhere long ago. And it was just recently found on an xray for something unrelated.

But also some problems.

1. He states he didn't know the risk of what he was doing, but when he was told not to come home he went to extreme pains to get home. He flew from Atlanta to Greece for his wedding, warned not to travel. Then flew to Rome, Italy. Warned again not travel. Then got to Prague, Hungary flew to Montreal, Canada then drove across the border to avoid authorities. Sounds like someone deliberately trying to skirt the system.

2. I'd hate to miss my wedding and honeymoon. But questions are now arising to whether a wedding took place. One article states "There was no wedding. They came for a marriage but they did not have the required papers." Good planning on his part. If I was the prospective bride I'd be pissed off.

Keywords

So I've realized for the last few posts that you can add keywords to each post and people can read those posts with those keywords only.

I'm anal enough that I'm going back and adding keywords to all my old posts. Hope this makes reading more enjoyable.

(I'm assuming people are reading)

Random walls

Image from freefoto.com

I'm walking out of work late yesterday. I'm tired. I'm on cardiac call i've been here for 12 hours. Not bad hour-wise but i've had to work with one of the stressful surgeons and just finished helping code a patient in the operating room.

I just want to go home and put up my feet...

All of a sudden there's a wall along the corridor where I usually walk out. It was open this morning

"Detour -->" I guess they're finally connecting the new building to the old one.
Now I wander through the basement and finally get to my car.

Perfect ending to a long day. Hope I don't get called back in.

Yay!

I got a page from a friend today saying oral board results were posted.

I passed!

It's about a week and half earlier then they said scores would be up, but I'm glad.
Relief.

Oral Boards - Done

I've been back from DC. Oral boards are done.
Yay!

Topics were anticipated. Did I study enough, hard to say... would studying more been more helpful... doubtful.

I think I did okay... but who knows for sure. I'll find out at the end of May.

At least it's over, for now.

Transvaginal Cholecystecytomy

In a word -- Yuk!

These words together mean removal of the gallbladder through the vagina.

Yuk yuk yuk.
If I had a vagina, you're not removing my gallbladder through it.

And to boot there's a Natural Orifice Surgery Consortium for Assessment and Research.

You can leave my natural orifices alone... I mean look what great scientific advances there are in this decade.

New York Times online via Book of Joe

DC in the spring

Ah to be in Washington DC in the spring.



Blossoms on the trees.

Spring is in the air...

NO!

I'm in DC for anesthesia oral board exams

Its 40 degrees outside.

There's a wind advisory...
The plane was shaking like a laundry dryer as we were landing... and I swear we were going sideways for several seconds.

AND I'm taking oral boards tomorrow.

I'm a little stressed

I'm back to the books for last minute cramming... maybe a short nap.

More later.

Drug interactions

A friend called and asked me: "Are there any drug interactions between Darvocet and albuterol?" Her friend had just had surgery and was on pain killers (Darvocet - acetominophen/proproxyphene) and wanted to take a puff on her inhaler (Ventolin- albuterol).

I said I didn't think so. The narcotic has lots of interations, but not likely with albuterol. "Why?" I asked.

"Well she saw this Law and Order where this girl poisoned her mom with darvocet and albuterol."

Hmm... Law and order? "You sure that wasn't darvocet and ALCOHol not ALBUTERol?"

"Hmm... yeah probably, see ya bye!"

I guess it's all in the details.

Clinic

Been in clinic a lot the last few weeks. Almost half my work time. By now i'm almost suicidal... I didn't go into anesthesia to do so much clinic

(no offense to those who are actually suicidal)

Room temperature

It's important to keep the patient in warm in most cases. Most cardiac cases this is not an issue much because the heart-lung bypass machine has a heat exchanger on it which allows the perfusionist to warm or cool the (patient's) blood as it goes through it.

We were doing a big cardiac case under left heart bypass -- where part of the blood is taken after it gets passed through the lungs, and rerouted to the femoral artery in the groin so that work can be done to the descending aorta with most of the blood flow being perserved. This is nice so that damage to important organs like the kidneys and intestines can be limited.

Since we have less control over temperature because it's only partial bypass, we had the room temperature way up. It was warm for me, but must have been killer for the surgeons who were wearing waterproof gowns, etc.

On of the attending surgeons was scrubbed in and asked for temperature to be turned down. He's generally very expressive. "Turn down the temperature or I'll vomit in the wound and the patient will get septic and die!" I just about died laughing...

(For those not in the know... sepsis in a severe systemic infection caused by bacteria. If you vomited into a patient surely this would happen but it's not a scenario you contemplate ... well ever.)