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.