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.

Hooray for Eyes

Here's the latest from Dr. Auker. I can now stop putting the Vigamox (the antibiotic) into my eyes! I still have to do the Vexol for another two weeks, but only twice a day, down from four. He did seem concerned that my eyes were rather dry, but my eyes have been dry before I got the surgery, so I know it's not associated with LASIK. After years of contacts, I'm not a very good judge of when my eyes are dry, so I probably wasn't putting the moisture drops in regularly enough. He put tear duct plugs in each eye, so that it will slow the drainage of my eye/lacrimal fluid. He also gave me more moisture drops - I was running low. The girl who got the low down from me before Dr. Auker came in checked my eyes again and I'm still seeing better than 20/20 - I am able to see 20/15 in both eyes, but it's slightly more difficult in my left, so my right may be slightly better than 20/15.

In other news, after dressing up "professionally" and wearing a white coat with a patient again, my mind is drifting to my dearth of decent clothing. I have no nice suits beyond the suit I bought for interviewing, I have no professional tops except a single blue blouse, and the only dress shoes I have are heels and uncomfortable. I wore tennis shoes to the patient encounter because a lot of the doctors I've shadowed wear tennis/sports shoes and it is only logical - if you're on your feet all day, you need durable, comfortable shoes, not ones that are just for show. I should probably invest in two pairs of "professional tennis shoes" - a white and a black pair. Ones that look like professional shoes but are actually really comfortable. But then there's the issue of body fluids getting on my nice shoes during rotations and residency...oh the scutwork shall be wonderful. Either way, no one commented on my wearing tennis shoes, though I think I was the only one in my group who did. I am painfully wardrobe-challenged.

LASIK Complete!

Well, I got my LASIK done yesterday - and I'm sure everyone is curious about the medical procedure. My first appointment was a while ago where they checked my eyes to determine whether I was a good candidate. Some of the criteria include nearsightedness less than -10.00, sufficient corneal thickness, no severe eye dryness, and little or no astigmatism or other eye problems. My eyes are somewhat dry, both were around -3.00, unnoticeable asigmatism, and a slightly thicker cornea than average, so I was a good candidate.

The second visit, they dilated my eyes and did other tests to get exact readings on my eyes, we discussed payments, methods of going about the laser eye stuff, etc. I went with the laser system for cutting the flap in the eye (instead of a hand held microtome) and LASIK (laser-assisted in situ keratomileusis). After a couple reschedules, my LASIK date was finally set for Dec. 4.

I was instructed to wear glasses (no contacts) for the week prior to the surgery, I had to take a Valium (5mg) 1 hour before the surgery, and have someone drive me to and from the surgery center. When I arrived, they took me into a room to analyze my eyes, I forget what the first test was for, but the second one was to map my iris (similar to iris-recognition for security) so that the laser could lock onto my eye. This was part of the "Custom Vue" LASIK, where they use Wavefront, WaveScan, and WavePrint technology to get a very accurate fingerprint of the eye, so to speak. Supposedly, it can also measure flaws in the eye 25x more precisely than traditional methods. Then they cleaned the area around my eyes, put in numbing drops and antibiotics, and we headed to the first station - the intralase machine (the laser which cuts the corneal flap).

This was the most uncomfortable part - they had to prop my eyes open clockwork orange-style, then attach a plastic fixture to my eyeball with suction, so it was completely fitted to my eye. Then the other end was attached to the intralase machine, and basically my eye saw those gray/white/black patterns you see in your eye when you press on it. Then I had to hold still for a moment and it cut the flap; I couldn't feel it, maybe there was a slight warmth. Then we repeated for the other eye and I went to another room for the LASIK laser procedure. They propped my eyes open again, taped my eyelashes back, added more numbing drops, and had me look up at the laser. The doctor folded back the flap on my eye. The laser itself was a green color, but there were bright dentist-like lights on either side, which were painfully blinding. As they focused the laser's position, there was a grid of red light that I saw pass over my eye. Then I held my focus on the green laser point for a few seconds as it did its work. I could smell flesh burning...not too pleasant. Afterward, the doctor replaced the flap on the eye and smoothed the lines of the incision to make sure it was firmly back in place. Then we repeated with the other eye and I sat aside for a bit while someone else had the same procedure done. Afterwards, my eyes hurt quite a bit - like there was sand in them and some of the chemicals made it difficult to open my lids. The doctor rechecked the eyes, said that the procedure went perfectly and the flap was back in place. About 2 or 3 hours after being back home the pain had gone away and I could open my eyes for brief periods of time.

As far as post-op care, I cannot use eye makeup, wash my eyes, do any strenuous activities or go swimming, and must put one drop each of Vigamox (Moxifloxacin hydrochloride) and Vexol (Rimexolone) into each eye four times per day, and use Systane (preservative-free) eye drops as needed for dryness. I also cannot rub my eyes and must wear goggles at night and sunglasses outside. I also have to be careful when doing activities that tend to cause less blinking, such as working on the computer, reading, or watching TV - essentially, I have to remember to blink or hold my eyes shut every so often. I have to keep up this post-op care for 1 week, but I have a blackberry app that lets me do as many different alarms as I want, so I have 1 wake-up alarm, 4 eye drop alarms, and 1 birth control pill alarm. I can make it play whatever song I want as the alarm, too, and change it for each alarm - if anyone's curious, this is the app.

The next day (today) I went back in the morning for him to check how my vision had changed, and I am 20/15 in both eyes - so better than 20/20 (standard). I have a followup in a week to make sure things are healing correctly, and other than that it went off without a hitch. It's great being able to see without contacts or glasses! It feels so weird that such a short procedure, which doesn't look or feel like anything changed with my eyes (currently, anyway) could suddenly make it possible to see super-perfectly clear.

As for the breakdown, Dr. Auker's costs for examination and supervision of the procedure were $2,350, use of the LASIK machine was $2,150, and the intralase machine was $600. My mom had originally offered to cover $3,000 as a gift to me, and when it turned out to be more, I covered the excess. So in total, $5,100 dollars for both eyes, $2,100 out of my own pocket, but I got 20/15 vision out of it so I'd say that's money well spent. I should point out that Dr. Auker and the laser center are more pricey than other options out there, and I do not know whether there is a substantial difference in quality - Dr. Auker treated my mom's eyes about 10 years ago when he was still with Kaiser and she is still happy with the results - he now has a private practice. Considering his experience, and the fact that he was performing LASIK successfully when it was brand new with good long-term results, made me feel more confident in his skills/knowledge and more likely to choose him over a cheaper alternative. To see his website, click here.