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.

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.

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.

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.

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

Appendectomy

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 =)

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...

Finished BLS and ACLS

Since I shall soon be starting rotations in hospitals, I had to go through BLS (Basic Life Support) and ACLS (Advanced Cardiac Life Support) training and certification. Didn't take too long, and BLS was a recertification so that was no challenge - ACLS was a lot of new material and new sequences of information, along with a refresher course on EKG reading so that was fun! I particularly liked the instructor, as he had 42 years of experience as a paramedic and emergency department (ED) technician so he had lots of case examples to share with us.

Some take-away points for normal people which I feel I should mention - as it may save you or a loved one one day:

3 main things to know for CPR

1. Are they breathing? Do they have a pulse? (if no...)

2. Have someone call 911 and tell them to try to find an AED (often in hospitals, schools, major office buildings, gymnasiums) - no use doing CPR if no one is coming to help.

3. Chest compressions - fast and hard - at a rate of at LEAST 100/minute, so we're talking about 2 compressions per second. When you do compressions, middle of the chest (approximately between where the nipples are), compress about 2 inches into the chest. On kids, 1/3 of the way. *FYI: If you are doing compressions properly, you may very well end up breaking their ribs - don't let that stop you - keeping heart circulation going is much more important than a broken rib or two*

If you are comfortable doing mouth-to-mouth on this person (child, husband, etc.) do only 2 breaths, head tilted back, covering nose, and then go straight back to compressions -compressions are WAY more important, so alternate 30 compressions then 2 breaths.

Another take-away note about Strokes...

If you or someone else starts having signs of a stroke (one sided muscle weakness, face drooping on one side, difficulty speaking) - CALL 911 - DO NOT DRIVE THE PERSON OR YOURSELF (unless you are less than a block from a hospital MAYBE). Reason? You may feel well enough to drive yourself, or you may think you can drive your family member, but if an ambulance picks them up, then not only will they get en-route care, the hospital they deliver the person to will be completely prepared, with the neurologist, cardiologists, etc. all notified and ready to take care of the patient. It can take 45 minutes of assessment and evaluation once you get to the hospital before they decide it's a stroke and can do any therapy - by then, it may be too late.

Why is this so important? Fibrinolytics - you basically have a 3 hour window where you can be given a medicine that will essentially dissolve the clot in your brain. I have known people who drove themselves while having a stroke, or who started having a stroke in the middle of a golf course and played through to the end before going to the hospital - if you want that shot at a Fibrinolytic, which will GREATLY INCREASE your chance of restoring brain circulation, get to the hospital ASAP.

Bottom line: If you have a loved one, pass on this information so they get the fastest possible care, or so they know what to do if this happens to you. Time makes a MAJOR difference when it comes to blood not getting to your brain.

Enough with the public service announcements though - time to get back to studying for board exams! Wooh! Diuretic medications.