Wednesday, July 27, 2011

Loooong Day

Well today was extremely long. Kinda surprised it didn't FEEL longer. Got to the clinic at 8:30am, expecting a short clinic day getting out around 12:30 or 1:00 - instead, the doctor was about 20 minutes late so we had a lot of catch up most of the day, and I didn't have the PA student with me so I had more patients to see than usual. I also did some injections and assisted with a skin nodule extraction - outpatient minor surgery at the clinic. Mostly stressful just because I wasn't sure how to do any of it, not that it was difficult. By the time the patients were gone it was probably 1:30, and I was trying to finish up my SOAP notes. In the meantime, the doctor was trying to get a bed in the OR for a patient with an ulceration in his intestines and was having trouble. Eventually it was scheduled for 3:00 PM, so we drove over to the other hospital around 2:15pm, I got dressed, checked the OR list of procedures to see how on time they were, and then rushed to the physician lounge to get something to eat or drink. Found an energy drink, elected to use the zero carb one, downed that while I waited for 3:00 to roll around, around 4:00 maybe the surgery started.

Today we cut into the first patient's abdomen, and pulled the intestines out of the abdomen and onto the patient's belly so we could look for any perforations that were causing the patient to lose fluid into her peritoneal space. This consisted of cutting away the connective tissue holding the intestines coiled and going through it at length to find stuff. It really looked like an evisceration. Got to see a bunch of new anatomy, and it was an interesting exploration - didn't find a perforation and the fluid was all clear, so it was probably from the pleural space. After that, the doctor had to do ANOTHER one, except this time the guy almost certainly had a perforation in his gut somewhere - he was in a lot of pain. We did the same thing as for the first patient, except we found the hole in the guy's sigmoid colon and the fluid in his abdomen was brownish. Yeah, pleasant. Anyhow, I got to see how you cut out a segment of colon and reconnect it. There are a lot of specialty clipping tools and ways of doing it that I hadn't thought of - it was very interesting. I mean, when you think about it, how do you get a piece of large intestine out and connect the tubes without spilling fecal matter all over the place? With lots of nifty tools and tricks, that's how.

Anyway, got through all that, by the time all this was over and the patient was back in his hospital gurney, it was 8:00pm. SO..... basically a 12 hour day. A few pluses: Saw some new procedures, assisted in new procedures, talked more with the surgeon, and people (including the surgeon) were addressing me by name for the first time. Guess they're starting to get more used to me.

As an aside, for anyone who has played RPGs, I started feeling like a total NPC today - following him around, if I lingered and he got away from me a bit I would jog to catch up, I'd be stuck in doorways or be hindering things (but honestly mostly helpful). When I got that thought in my head it was hard to not laugh. Another day of surgeries tomorrow, hopefully just the three that I know are scheduled. Time to take some ibuprofen for my aching feet - I didn't know we'd have surgery so I stayed in my dress shoes all day and my feet are KILLING me!

Tuesday, July 26, 2011

General Surgery Rotation - Week 2

So far the week is going well. Monday we started out with some clinic cases, and then we headed to do a thoracic surgery - removal of the lower left lobe of the guy's lung. It was pretty interesting - had to break open the ribs, and then slowly remove the lung - it was pretty involved. Amazing that lungs, which seem so delicate when you read about them and such, can handle a person shoving them around with their hand. I got to feel the diaphragm, descending aorta, lung tissue, saw the heart beating in the guy's chest - feel pretty privileged to be able to partake in things of that sort. Few people can say they've had their hands inside a living person's rib cage.

Today went well also, had a few surgeries, this was the last day the PA student was there, so for the next few days it'll just be me and the surgeon until the next PA student arrives. I assisted in a neck lumpectomy and a breast lumpectomy - it's amazing how vascularized fat is. With the neck fat there were sprays coming out here and there - with the breast tissue I've come to expect that. Had to find the lymph node, and I did an essentially complete final suture - the surgeon actually said it looked good, so that felt really good - all I really want is to not look like a complete idiot. Anyhow, tomorrow is more clinic patients - maybe I will be done by 1:00 or 1:30pm - that would be nice, since today I was done at 4:30, and I want to get more of my studying done.

In other news, my boyfriend and I have our 5 year anniversary coming up - we'll be dining somewhere in San Francisco - should be nice.

Thursday, July 21, 2011

Day 3 and 4 General Surgery

Yesterday I went in and took histories most of the morning, tried taking a thorough history, then tried to make them more focused. My notes are looking more proper, I think it helps that we didn't have any minor procedures that day, which are not quite surgery, not quite a normal visit, so those are a little challenging to document. Starting to talk more to the surgeon, which is good. He's warming up to me, I suppose. His 1:00pm surgery ended up getting pushed to 3:30pm, so me, the surgeon and the other student mostly sat in the physician lounge chatting for a while. It was nice, getting a bit more comfortable. Then we went to the surgery, it was an exploratory laparoscopy, which was interesting to observe. Ended up extracting an ovary and ovarian cyst (benign).

Today he had a hernia repair in the morning, during which I assisted. I got a few pimping-type questions, which was fun, and the anesthesiologist joined in as well and he was impressed that I seemed to know stuff - "It's refreshing having bright students come through." I don't know if it helps that I'm a girl, but at any rate, it was nice to get a little positive feedback during the experience. I also lucked out that the questions I got were rather infectious-disease related, which of course is one of my main interests. I still got to make the first incision on this, and also tied off the last suture for the mesh.

The next surgery I observed, it was a fistulotomy repair. The scrub nurse looked like Dr. Chase from House (teehee). After that we went to a different hospital and I assisted with a VAP insertion (Venous Access Port), in which we insert a tube into a vein and there is a subdermal port attached to it which is used to make it easier to administer chemotherapy and such. So, my part in it was identifying the trajectory of vein via syringe needle, then inserting a guide wire about 2-feet through the jugular vein, guiding a plastic tube around the guide wire, and then removing stuff after we got the port connected. I also got to do the subcutaneous suturing. Final surgery was observing another hernia repair and that's the end of the day. We were expecting to do a thoracotomy, but that guy got postponed to another day. I also got to watch a chest tube insertion on a guy with pneumothorax and lung cancer. Interesting, for sure.

Oddly enough, I find that doing the surgeries themselves is a lot more interesting than meeting with patients and writing SOAP notes after the encounters. I guess because it feels like a lot of busy work and they don't feel like regular patients since they are all referrals for surgery it feels like a pointless exercise. Also, in surgery you aren't dealing with people, you're just dealing with their flesh - it's like a mini-crafts project almost. You have cutting, pasting (I guess cautery can count as pasting - or cooking, haha), sewing, organizing, sculpting... I duno. It's interesting. I still highly doubt I would go into surgery, considering the years of training, the unpredictable hours, and constant standing and high risk of lawsuits, but this rotation is turning out to be a lot better than I was expecting.

Tuesday, July 19, 2011

Day 2 General Surgery

Today I had my first actual scrub-in surgeries. The first surgery was an umbilical hernia repair - I scrubbed in a bit early but got some of the awkward "what do I do" stuff out of the way at least. When you are 'scrubbed in' the scrub nurse fits you with your sterile drape and gloves that you will wear for the rest of the surgery - after that you cannot touch anything that isn't within the sterile zone. So they were still prepping a bit and I had to stand by - beginner's mistake, and at least the surgeon wasn't there yet to notice.

Me and the other student are alternating in assisting, so I was first in assisting, and got to make the first incision. The surgeon was a bit more relaxed and talkative today, maybe because he is in his element and not having to worry about patients (interacting with the person, I mean, not the body). After that I mostly held clamps, dabbed gauze, and tied off a few stitches. We inserted a mesh to prevent the herniation from protruding. The next surgery was in a different hospital so we sped over there in our respective cars and this time the other student scrubbed in, so I observed. It was rather short, another hernia, so that wasn't too bad.

During the lunch hour, there was a cancer session where radiologists, surgeons, and others meet to discuss particular cancer patients and approaches to diagnosis and treatment. We got free lunch, so that was nice - the doctor's lounge also has regularly stocked varieties of drinks, including energy drinks, so that's pretty awesome - on surgery days I get free energy drinks ^_^

After that we observed half of a double mastectomy and I assisted with the second half - this time both the surgeon I am following and another surgeon were working, and I was mostly assisting the latter. They are both nice, were chatting with each other about their residency experiences in various places, etc. At the first hospital there were eye shields, and I was really wishing I had an eye shield for that mastectomy, since there were a lot of small blood vessels getting cut here and there, and a few times it barely missed my face. Again, mostly holding, snipping, or dabbing. Got out about 4:30 PM so all in all not a particularly long or troublesome day. Tomorrow I report to the clinic around 8:20 AM and we have a surgery in the afternoon around 1:00pm so we shall see how that goes, whatever it is.

Monday, July 18, 2011

Day 1 General Surgery

Back from vacation, time to hit the ground running -

So, started my surgery rotation today around 9:00am - I knew the doctor would not be there until around 10:30am due to a previous surgery so I reviewed the patients who were coming in that day, and then did patient interviews. After doing an interview, once the doctor got there, I would follow him into the room and he would examine the patient. The two nurses/PAs are quite nice, and there is a PA student from my school who is there with me for the next few days so they all showed me the ropes a bit - what is disposed, what is washed, etc.

At the end of the day I wrote up SOAP notes of the various patients, which includes their history, observations, the assessment, and plan for their treatment. Spent about two hours doing that, hopefully I'll go faster next time. Tomorrow we have an inguinal hernia surgery and possibly a bilateral mastectomy - there's also a cancer meeting about one of the Dr's patients but I don't know if I get to go to that.

For the rest of the evening, going to look up information about inguinal hernia surgeries, mastectomies, and other surgeries that I saw today, and get started on my reading assignments. One observation about the surgery rotation - I basically have to have as much initiative as possible, so suggest helping with things, follow the doctor into rooms - no waiting to be told what to do or asked to do this or that. Good training, requires a lot of energy though. We'll see where this goes.

Tuesday, July 12, 2011

Post-COMLEX Step 1

Well, that was a long test, that's for sure. So, I took COMLEX on Monday, it is a 400 question test, separated into sections of 50, no real theme to the sections, they feel like pretty much random collections of topics, and you get 60 minutes per section and a 40 minute break for lunch after the first 200 questions. Took BART into San Francisco, arrived at the Prometric testing center at 7:30am, started the exam around 8:15am after everyone got checked in, pockets checked, scanned with metal detectors... at least cheaters have a difficult time. They also do rounds in the testing area every 10 minutes.

Anyhow, there were quite a few repeat questions - what bug is causing this infection, what does this slide indicate, it's all a bit of a blur right now. I kept tabs of how many I was "guessing" on, and by the end it felt like maybe 40% of the test was my best estimate? But the questions are each weighted between 0.5 and 5 points, so it's really hard to know about how many you need to get right to pass or get a proper score. My practice COMLEX exam had me at slightly above average, and my question bank percentages were fairly respectable, so I almost certainly passed and most likely have a score acceptable to most Family Medicine, maybe some Internal Medicine, residencies.

I also got some information about my General Surgery rotation which I am starting on 7/18/11 - clinic days are Monday, Wednesday, and Friday - where he will have me practice taking patient histories and then we will do physical exams together; Tuesday and Thursday are surgery days.
The surgeries I can expect to see performed include:
Inguinal hernia
Umbilical hernia
Lap Chole (Laparoscopic Cholecystectomy)
Excisional breast biopsy
Injecting hemorrhoids with a sclerocing agent
Port a cath placements
Pilonidal cyst excisions

So... lots of stuff in the future! I'm glad the clinic days are so short, as it'll leave me a lot of extra time for studying and personal time =)

Sunday, July 3, 2011

One more week to go...

One more week until I take COMLEX, going to have to step up and really study. Took a break the last day or two, just been stressed out. Plus after I take the test it is off to Oregon, then the day after I get back it's time to jump into the general surgery rotation and patient interviews and scrubbing-in and all that fun stuff. I've gotten my badges for the two hospitals I'll be at for now, and have a surgery rotations book to review while I'm in Oregon. It's getting really hot now in the bay area, so it's getting harder to focus. Must stay strong! Time to do some practice questions...