Slow Day

Today was rather slow by comparison - only saw two patients.  In the morning there were lots of quickies here for some injections (either Supartz or corticosteroids) and one or two who didn't want a student.  Spent a lot of time sitting around reading JAMA articles.  I came across a few interesting tidbits.

1. Onchocerca and Dranunculus, both parasitic roundworms, are in the process of being essentially eliminated from the human population by the World Health Programme.  Onchocerca causes river blindness in South America, and Dranunculus is also known as the Guinea Fire Worm, and if you don't remove it slowly from a person's arteries then it will die and cause a reaction that will kill the person.  You hear about viruses like polio or smallpox being eliminated, or maybe malaria, but rarely about parasitic worms.     

2. Bladder cancer is higher in men than in women - I hadn't really thought about this before now.  Bladder cancer is strongly linked to cigarette smoking, particularly to a chemical in cigarette smoke: naphthylamine, which  is also found in certain textile dyes.  However, it was previously thought one of the reasons men were more susceptible was because men were more likely to be smokers, have unhealthy lifestyles, and work in environments that expose them to carcinogens.  Now that women are working in a lot of the same fields as men, the incidence has not increased an equivalent amount.  A study in 2007 showed that mice without the testosterone/androgen receptors who were exposed to chemicals linked to bladder cancer did not get any bladder cancer, compared to mice with the receptors who nearly all got bladder cancer (~90%).  It would seem that the same mechanism behind prostate cancer may be involved in development of bladder cancer in men.

3. JAMA includes a previous JAMA article from 100 years ago to the day at the end of each issue.  One of the old articles about digitalis/foxglove and its use as a medication for arrhythmias and other heart problems had a very interesting line in it.  After going at length about the benefits of high doses of digitalis, the author writes: "For that reason, a daily large dose of digitalis is advocated indefinitely to keep the weary heart a-going on its rapid journey to an eternal standstill."  That article was written in 1911, and the last part of that line has a very poetic, almost morbid sound to it.  Rather unexpected when I was reading the article.

At the end of the day I had to go to didactics, where a guy who reminded me a lot of Jim Carrey was telling us about Clopidogrel, and how it compares to Aspirin - his main argument was that Clopidogrel (Plavix) is treated like a substitute or necessary adjunct therapy for Aspirin, but in reality there is little evidence it is more efficacious than Aspirin, or that dual therapy would benefit anyone besides those with cardiac vessel stents or in an acute cardiac event.  It was interesting, he was going on a bit about drug reps and such - since I studied a lot of that in undergrad for my medical history classes, it wasn't anything that new to me.  Anyhow, time to get some reading done and try to recharge for tomorrow.

3rd Week of FM

It's starting to feel more routine each day - the nice thing is the patients are always different.  I don't know why people complain that family medicine is the same old thing - yeah, it's always talking to a patient about what's going on, but at least it's a different thing with each patient usually.  

We had a deaf couple come in, and naturally they couldn't speak, so we had to communicate by hand writing back and forth.  I've been trying OMM on some patients but usually they are so uncomfortable from whatever it is that is ailing them that I don't feel super comfortable treating them, since touching them or making them move puts them in a painful position.  I got to help drain a MRSA (methicillin-resistant staphylococcus aureus) ulcer today on some guy.  Perfect example of patients being horrible historians - when I saw the ulcer I specifically asked him "do you have any history of having cellulitis, or MRSA, or other skin infection?" "mm...nope."  "Are you immunocompromised, like taking chemotherapy or have HIV?" "nope."  So of course when I report back to the doctor he looks in the patient's chart and see's "Yeah, he's had two or three bouts of MRSA, each time was treated in a hospital for it."  You would think a patient would remember that sort of thing.  

In the meantime, the topic I chose for my presentation is acute myalgia, which is an incredibly broad topic, so it will be hard to narrow it down, and categorize things in a way that covers as much of it as possible.  I'm still doing translating here and there, and working on SOAP notes in the office.  This was a good weekend but I was up late last night and there was an accident on my way back from Napa so my usual 40 minute drive back turned into 2 hours.  Blah. 

Translations and Presentations

Today felt rather long, but it was generally busy at least.  Didn't see too many patients in the morning, but the afternoon was packed.  One patient in the afternoon who came in had suffered a fall in a Target store and she and her husband/boyfriend were there - both were Spanish speaking.  Since the doctor I was with today spoke a modest amount of Spanish I spent a lot of time translating, which was interesting and my head and tongue hurt by the end of the session.  I don't know if it's because it is tiring making your mouth say different accents back and forth, or if it's just because I don't use Spanish all that often but it was a good practice session.  By the end, the patient and her companion were both very thankful I was there and were glad to have gotten so much attention at last - she had a multitude of problems, like herniated disks, possibly a broken rib, neuropathies.  

Also, I discussed my Case Presentation project with my preceptor - during the family medicine rotations, we are to do a presentation on a patient/topic and present it to all the doctors in the family medicine department - it has to be 45 minutes long, powerpoint presentation, with a handout or two.  I attended our didactic lectures yesterday and that was a reminder that I have two-20 minute presentations through Touro that I need to do for my fellow students, and get feedback.  I'm of course more nervous about the 45 minute one where lots of doctors will be asking me questions and critiquing me, versus the positive feedback/nice constructive criticism of an audience that is mostly people from my class.  And unfortunately the 45 minute presentation is the first one I have to do, so I don't even get to warm up with the 20 minute ones.  Buuuut - that's not until the third week of September, so I have some time.  I am going to come up with the powerpoint this weekend though and have my preceptor go over it.  

Another Week of FM

Today I was supposed to be with this one doctor, but ended up getting sent to a different one who kind of reminds me of George Washington Carver - skinny black guy with the same haircut and mustache.  Anyhow, he was nice but he did not seem to interested in any of the patients he saw - maybe he is just jaded or tired or not happy to be back after a weekend but he looked kind of blase or worn out.  We saw a couple elderly patients with mild dementia - kind of a harrowing feeling, hoping that your parents or yourself won't end up in that situation.  

After that in the morning, I had my lunch but decided the two recipes I had experimented with for my week's cuisine were both rather unappealing.  I'll modify them tomorrow after my half-day so that I can still make some use of the ingredients.  The cucumber soup is mostly unsalvageable but the root veggies I think I can turn into something edible.  In the afternoon today I was back with my main preceptor, and we saw a few interesting cases - a girl for acne, a woman with possible prodrome phase of herpes zoster, and a couple people with gastroenteritis (one Spanish-speaking).  I'm keeping my fingers crossed that I don't get a stomach virus - I can't remember the last time I had a really bad gastrointestinal illness, and I'm hoping it won't be for a while yet.  I've been taking probiotics daily so I should be covered as far as bacteria, but viruses?  I don't know if probiotics help with that at all...  

Tomorrow I am back with the sports medicine doctor who is associate dean of clinical education.  I need to show him a SOAP note of an interesting patient we saw on Thursday, who had a dorsal expansion hood rupture on her second digit knuckle.  It's only a half day so hopefully I'll be able to get home, make some food, and get some decent studying done.  Waking up so early is killing me, hopefully I can get through tomorrow.  

Also, there is a family medicine conference in LA that I may go to on October 15 and 16 - all the residency programs in California for family medicine should be there, and it would be an opportunity to visit a friend of mine and my boyfriend's, and my boyfriend's family.  It would only be for a weekend and we would drive down there, but I think it would work out.  Just have to sign up.

End of the First Week

Family Medicine is off to a good start - I've seen a few patients multiple times.  One example - I saw an elderly man with the sports medicine doctor, then I saw his wife with another doctor, and then I saw both of them with the man's primary care doctor.  I have also been practicing writing SOAP notes and trying to refine that practice.  I still have good rapport with all the doctors, and am getting a better sense of how to conduct patient history and physical exams.  One gray area that I was a little nervous about was doing a basic physical exam on someone - I didn't know how thorough I should be when my preceptor is not there (mostly as far as having the patient disrobe, doing genital exams, etc).  The first time I came across this, I decided to do a thorough history, do some health education, and then wait and see how she conducted the 'complete physical'.  I went through everything, and included information about doing monthly self-checks for testicular cancer (highest rates in men in their 20s, 30s, and 40s, unlike prostate cancer which is highest in men over 50).  After the doctor did the exam (which didn't include a genital exam), she mentioned that normally she does that if the patient has complaints and I told her I did some patient education on that topic and she was very pleased.  She also seemed satisfied with my SOAP note that I did that day.

One small snag I have noticed is that my preceptor leans toward holistic/natural medicine.  That is perfectly fine with me, since I like the idea of combining lesser-known but similarly efficacious remedies for various diseases.  Also, according to our review forms, we are graded on whether we make references to medical studies and readings.  I thought a good way to combine the two would be to pick one or two things that she talks about that I am interested in and then look up articles that go into more detail.  On my first day with her, she cautioned a patient to get refrigerated probiotics because it was her understanding that ambient temperature probiotics are not effective.  Since I myself have some ambient temperature probiotics, I wanted to see exactly how poorly they fared against refrigerated ones - and despite going in with the expectation that she would be right, the study I found (from 2010, a pediatric medicine publication) found that they were equally efficacious in reducing the length of bacterial diarrhea compared to placebo.  I mentioned this to her as nicely as possible and she didn't seem to have a problem with it, which was good.  However, the next thing I thought I chose to look up had to do with how glucose levels exacerbate atopic dermatitis (AD), because she cautioned a patient to avoid food with high carbohydrate content in order decrease her overactive immune response.  I started looking up information on PubMed today about that and the first article on the topic that I found stated there was no change in symptoms in patients with AD when they were placed on sugar-free diets.  I only have partial access to PubMed at the moment, but I emailed our library director about how to gain access remotely (I know I can access it from school computers).  She expects me to have looked into this topic and I really really don't want to have to contradict her again - I want her to be right about these things, and I really like her too, so I want to keep her looking favorably on me.  If I really can't find any studies in favor of her sugar free diet, I will at least try to find a few on other factors that may increase AD (she also mentioned caffeine, antibiotics).  She is an MD for what it is worth, as are all the other Family Medicine doctors I am rotating with at Kaiser.

A final note on OMT - I have decided that I want to find ways to practice a little more OMM in the clinic, since it was part of my training, it can provide relief for some patients, and it will be included in my Step 2 board exam practical.  Considering this, I have made a goal to treat at least one patient each day with some form of OMM - most patients are very open to trying it.  The first patient I tried it on was suffering from low back pain and was a Spanish speaker, so it was a little challenging to communicate what I wanted him to do, and he was also in pain, so that was a little intimidating.  The next patient I tried it on was a middle-aged woman who had some neck/shoulder pain, which seemed muscular in origin, so I decided to do some occipital release, muscle inhibition, and long cervical muscle stretches - I was still doing some treatments when my preceptor came in and she was very approving.  The patient did report some decrease in pain, but again, I need more practice with patients.  Since I'm a little nervous about treating patients with real complaints (I don't want to make things WORSE) I am considering doing an OMM elective rotation.  I am still trying to schedule an ID rotation, but the guy hasn't emailed me back and it is really difficult to get anyone on the phone - I'm always transferred to voice mail or some department that doesn't know how to handle my request.  I'll try again next week, but the time I have left to schedule it before getting randomly assigned is ticking down...

I have also started listening to German audio lessons and audio books on my way to and from the clinic - it takes me 45-60 minutes each way.  I was looking for some audio books for Harrison's Principles of Internal Medicine (a huuuuge reference book) but none that were free.  I already have a hard copy of the book and online access, so I'll have to do that during my non-driving time.

More Family Medicine

Family Medicine is still going pretty well - the patients all seem to like me, and I have gotten to see a good range of ages, from kids 3 years old to adults 91 years old.  I have spent time with two general family medicine physicians and one sports medicine doctor (who also happens to be associate dean of clinical education at our school).  I've been trying to do readings on the stuff I see in the clinic, and stay engaging with the physicians.  I get along with all three of them really well, and I get the sense they do not mind having me around.  We had a little snag up with the scheduling so the dean was not quite expecting to see me today, but it worked out fine.  I talked to him a little more about some stuff, and near the end he said he was glad that I'm going to be with him two days a week instead of just one.  I also asked him if my timing on patient interviews was okay and he said that he would have let me know if I was going too fast or too slow, so I'll take that as a good sign.

Yesterday was good as far as patient interactions - a middle aged man came in yesterday and we diagnosed him with an inguinal hernia, and I was able to palpate bilaterally and up the inguinal canal - first time on an actual patient and not an actor.  Also one of the patients, a real talker who probably held me up a bit longer than I'd have liked, complimented me to the physician that day, saying that I was going to be a great doctor and was really good at talking to patients.  The more positive things said, the better - I just have to keep doing well and not let anything negative creep up.  I still feel pretty tired at the end of each day, and it's looking more and more like my drive is an hour each day - I have started listening to German audio lessons in the car.  Today I got off earlier than usual because the doctor I was going to be with this afternoon was not around and most of the other doctors in the office were not there this afternoon.  Time to catch up on my studies!

Starting Family Medicine

First let me say...wow.  Family Medicine is such a far cry from surgery.  The preceptors are so much more talkative, nice, and helpful - the interactions feel so much more normal.  We have been seeing a good variety of patients, including patients with asthma, bladder infections, osteoarthritis of the shoulder, palmar psoriasis, cirrhosis of the liver, and doing plenty of patient education also.  I've been grilling most of them about how they like working for Kaiser, since I am very interested in working for Kaiser one day - and all three pretty much love it.  Two of them are a married couple (though with different last names) and they used to have a private practice and she says they made more money in private practice, but it was much more stressful, and they could never take vacations, and had no life, compared to now.  Also, watching them deal with the electronic medical record system looks very appealing - they can finish encounter notes so quickly.  I told them I came from surgery and they chuckled, saying that I'll have the briefest notes of all of them after that, since surgeons are really brief.    

The biggest difference is in the question-answer feel - when I ask questions, I feel like they acknowledge that I am a student and have no problem telling me things.  When I tried that with the surgeon, he seemed more of the attitude of not wanting to teach me about stuff like that, that he would rather have me self-study and just quiz me when he felt like it.  Maybe it's because Family Medicine doctors are more relaxed and used to doing patient education.  It's a fairly stress-free rotation, so far.  I finished my first weekly quiz, most of it was either easy to look up or easy to discuss.  We have a quiz every week or two on blackboard, so we have to go through those.  I also need to be working on some readings and doing practice questions I think, but it's tough to get to everything when I get home at 6pm and have been up since 6:30am or so.  

Last Day of Surgery

Friday was my last day doing general surgery - we started out that morning at 8:30am with a patient with swelling of the left leg of unknown etiology - they had already ruled out DVT, osteomyelitis, and had essentially ruled out infectious agent, since there was no gas visible on any of the X-rays, and there was no surface involvement.  When we went in to get a muscle biopsy, his leg fat was swollen with fluid, just watery fluid - so there's a chance it was severe lymphedema or venous stasis due to CHF or another underlying problem.

Anyhow, I got to stitch that guy up and then ran off to find the doctor at his clinic, where we saw a few clinic patients, I helped dress some wounds, etc.  At the end he met with me to discuss my review, which consisted of him mostly asking me questions about how I liked the rotation.  He also asked me to grade myself, and I was a little on the humble side, so he gave me a little talk about not selling myself short and to focus more on selling myself and recognizing where I am doing well - especially for residency applications.  But other than that, he said I have done very well and that if I continue to perform like this in my later rotations, I will be successful.  

Second to Last Day of Surgery

Today was fairly interesting.  Our first patient took 3 hours.  She was a morbidly obese wheel-chair ridden woman with diabetes and she had a major ulcer (about as big as my palm) on her lower buttock by her vagina and one of her labia had a lot of sores, from when she has self-catheterized herself.  The surgical solution was to remove the middle portion of both labia (they have to match) and cut a flap, cauterize the big sore, and cover it with skin.  Her labia were gigantic, each one was about as wide as my arm.  This was, again, due to extreme obesity.  After three hours everyone was pretty sick of the case.

The second one was a gallbladder surgery, open (not laparoscopic) because the gallbladder was actually a "porcelain" gallbladder, a term to mean that the gallbladder has calcified.  There were also significant stones in it, and it was chalk white (hence the name).  Normally it is rather radiopaque, but the radiologist make any major comments about it, so it was missed initially until the first attempt at a laparoscopic repair.  Once it was out, it was rock hard - and the walls were pretty thick.  Inside instead of the typical greenish-yellow bile, there was this light yellow fluid, probably mostly cholesterol.  

The next two cases were lumpectomies for breast cancer, not much to say about that.  Didn't really get to do any suturing today, but tomorrow there is one surgery - a leg incision and drainage, because it is a cellulitis case (most likely).  Had to buy some thank you cards today, and should get some studying, but a friend is coming to stay with us for a week so I shall be very preoccupied with fun social stuff.  

Long Day of Surgery

Well, another surgery day is at an end. I was first-assist for a cholecystectomy and a thoracotomy plus decortication. The cholecystectomy was fine, went about as expected - and I sutured up two of the short incisions and they looked quite nice. The thoracotomy is where it starts getting interesting - it was on this 22 year old obese autistic individual, very obese. We had to go through 4 or 5 inches of fat to get to his ribcage where we had previously inserted a chest tube to drain pleural effusion. The guy had a really bad pneumonia infection and it had caused empyema, so we needed to go in, break a rib, spread his rib cage a bit, and detach as much of the pus-covered fibrinous exudate as we could - it was really remarkable how much there was. Imagine peeling really glued on labels off a glass beer bottle, except instead of glass it's lung tissue and the label is dense clotted blood, pus, exudate, and fibrin material. It took a total of 2 hours to do the surgery.

After that I observed a cholecystectomy, but this was kind of an odd case because the woman had a standalone piece of liver, about 2 inches by 1 inch by 0.5 inches, living by itself on her gallbladder. It was really weird, it had it's own blood supply and everything. At any rate, same procedure took place - removed the gallbladder along with that tiny chunk of free-living liver, and stitched the woman up. She took a half hour to come out of anesthesia and even then she was too weak to do much so they decided to intubate and let her sleep and recover overnight.

In other news, my car needed to be repaired, battery/alternator trouble and the cost is gonna be about $2,000 - really painful to think about. At least I have loan money for this sort of thing - unfortunately they still haven't disbursed the majority of my loan money because there is some problem with my stafford loans over at the main university headquarters on the east coast and they are waiting to hear back from them. If I don't hear anything tomorrow, I'll bug them again.

Also, I contacted an infectious disease specialist who works with AIDS patients and he told me to email him so we could set up the rotation - I haven't heard back yet, but hopefully tonight or tomorrow he will respond and I'll know if/when my infectious disease rotation will be. I'd really like to do that, we shall see.

Starting the Last Week

Well, after a nice weekend with friends, boyfriend and family, time to get back to work. Today I helped drain a cyst, and dress a wound, as well as finishing up the suturing on a VAP placement. It worked out pretty well, the suturing looked good, and the doctor seemed to be in a decent mood. Got out at a decent time, but ended up having to take the car into the shop. I have a rental at the moment, which is kind of a hassle, but at least it's getting stuff fixed and I'm getting a detail, so it should be nice and pretty when it gets back.

Later this week there are a few other surgeries, nothing particularly radical, but it looks like a nice load, nothing too stressful. On Thursday a mutual friend is coming to stay with me and my boyfriend for a bit and there should be some nice social fun going on this coming weekend. Next week on Monday I start my Family Medicine rotation at Kaiser Permanente - here's hoping it works out all right.

Connecting with Patients

Despite this being a surgery rotation, where you spend most of your time cutting into unconscious people, I'm getting to connect with quite a few patients in unexpected ways.

First off, yesterday during clinic hours I was interviewing a 34 year old Hispanic woman and getting information about her concerns about a benign lump in her breast. However, as we were talking about her allergies (raw onions) and I asked if anything else made her throat swell up like that, she said that the last couple weeks her throat has felt more swollen - like there was more fullness. She also felt like the back of her tongue was swelling more. Considering her race, age, gender, and that symptom, I thought I'd ask her a little bit about thyroid problems - turned out she was having cold intolerance lately, extreme fatigue, difficulty sleeping, palpitations/chest pain/anxiety, and her father and aunt on her father's side both have thyroid disorders. I asked her if she had talked to her primary care physician about this and she said no, that her PCP doesn't really talk to her about that much - that she's really rushed. I told her that I was thinking it could be a thyroid problem, that if I were her doctor I would want to check it out but that I would run it by the surgeon and see if he was willing to look into that. I mentioned it to the surgeon, as humbly as possible since I am terrified of sounding like a know-it-all medstudent who tries to diagnose a million things, and he immediately said "Sure, we can order a thyroid panel."

I don't know if it was the fact that I had actually made a physician-like decision in a patient's health, was suddenly afraid that I might be wrong or out of my mind, or just that the surgeon had actually taken my concerns seriously - but I was baffled for a moment. Of course, it could be that she is just tired from having two young children, maybe she is anxious from having a breast lump, maybe the chest pain is related to muscle pain in the breast, maybe the throat swelling is just an incidental finding, or maybe her cold intolerance is just in her head but it was exciting to actually have a tiny feeling of what it is like to be a physician.

In another situation, today after we finished what we thought was the last surgery for the day, it turned out that we were going to see an appendectomy patient. There was a 9 year old girl in the emergency department with acute appendicitis. Before I knew anything about the case, the surgeon told me to go to the ED to check out the patient and wait for him there. When I got there, I found an adorable teary eyed 9-year old Hispanic girl and her father, grandmother and uncle. Her father spoke pretty fluent English, but her grandmother and uncle both did not. Since they seemed to understand me when I spoke Spanish, I carried on a conversation with them, telling them a little bit about the surgery, that she would be put to sleep for it, that I would be there in the OR with her. The grandmother was keeping it together pretty well but when the little girl started to cry she started crying too, saying to me (in Spanish) "Since we cannot be there, can you please speak to her on the way to the room and in the room until she falls asleep so she isn't so afraid? Since you speak Spanish..." I almost started tearing up there and told her I would.

Since I was taking on the task of guiding this little girl to the OR, I took a moment there to talk to her a little, tried to get her mind off the impending operation by asking about brothers or sisters, about pets or anything. I remembered a story about Madeleine and how she actually had her appendix out and asked her if she knew the story and she said she did so we talked about that a little bit before the Anesthesiologist came. He was very nice as well and spoke very broken Spanish so that helped too.

When we got everything in the OR set up, we got the laparoscopic tools set up and the surgeon let me staple/cut the appendix out, as well as bag it in the collapse-able bag and pull it out through one of the tubes. He was getting a little antsy to get out of the OR near the end, probably since it was an unplanned surgery, so it was a little nerve-wracking but my fellow PA student reassured me that I did a great job and that it was really exciting to watch. Quite a fun filled past couple of days. We were going to discuss how I have been doing on this rotation, but he said we could do it tomorrow, so tomorrow morning I'm to remind him about that. No clue what he will say, but hopefully it'll be good. I'm glad my Spanish-speaking skills are coming in useful these days - now that I think of it, one of the other Spanish-speaking patients' daughter (middle aged) who was translating for me in the room on a clinic day complimented my Spanish skills in front of the surgeon. I wonder if he sent me to the room early today so that I could talk to the family with that in mind.

Either way, tomorrow is another clinic day, and hopefully constructive feedback from him about my performance, and maybe that woman got her thyroid function panel done for me to check on it. It'd be exciting if I successfully diagnosed someone with something that other doctors hadn't identified yet.

Colectomies Galore

One of the days last week that I was shadowing surgery had two Colectomies in a row, in which a portion of large intestine needed to be removed and reconnected (anastamosed). It was interesting because I got to see two very different approaches to anastamosis.

The first case was a patient who had a very large volvulus, or twist, in the ascending colon. A volvulus can occur in the ascending or descending colon, because those portions are fixed at the hepatic and splenic flexures (respectively) and the lower portion is hanging freely, with the potential to get twisted about itself. The volvulus was pretty big, about a foot long and 1/3 of a foot in diameter. After it was clipped off on both sides and removed, there were two pieces of colon that needed to be anastamosed and those were connected the same way I mentioned in the previous entry.

The second case was a patient who had had an emergent colectomy and colostomy bag put in, without a reanastamosis, so in this case they were going back in to finish up the colectomy, and anastamose the pieces to the rectum. The difference in this case is there is not enough room by the rectum for a surgeon to work very easily with his hands and clips, so instead they did the majority of the procedure laparoscopically. Once they had prepared the colon end that they wished to connect to the rectum, they inserted a circular disk with a metal male port perpendicularly. This produced an end of intestine that had a circular disk within the very end, and through the center (where the lumen would be) the male prong was sticking out. They then took another circular disk, except with a female port, and pushed it up the rectum to the point that they wished to create the new lumen and pushed the prong through the wall of the intestine at that point. They laparoscopically connected the two ports, producing a metal connecting rod between the two disks. The metal connector then approximated the two disks, to the point that there was a seal between the two parts of the intestine. The disks then cauterized the area and the entire apparatus was removed, leaving in its place a new lumen created between the sigmoid and the rectum for bowel contents to bypass the area that had been removed. I had never heard of this type of procedure before, so I was kind of clueless as to what was going on for the first half hour of the procedure. Mental note: Find a page later to link to procedures so that it's easier to understand what I am describing...

Well, more surgery clinic appointments today - I should also be meeting the new PA student from Touro who will be sharing my preceptor for the rest of my rotation.