Apologies...

Due to the losers who have such time on their hands to be able to spam my blog, I had to change the comments so that only registered people can comment. Since pretty much only my mom seems to comment, I don't think that'll affect too many people, but I felt compelled to let yall know! Also, apparently they can change my pictures on the blog to porn, and I don't know if eBlogger has fixed whatever lets them do that, so if you ever notice any inappropriate material on here, you can safely assume that that was not my doing, and please let me know ASAP so I can fix it....thanks!!!

Residency Interviews

So I've been on a few residency interviews in the past couple weeks, and let me just say....residency interviews RULE!!! Med school interviews are terrible - at best, the questions you get are variations on the general theme of "why in the world should we let you come here?" On residency interviews (4 now), I have only been asked one relatively serious question, and none at all pertaining to medical knowledge. The gist of residency interviews is, "What can we say/do to make you sign a contract here?" So here is what makes residency interviews so great: First, they pay for you to stay at nice hotels. And not just for the interview itself. If you want to come back for a "second look" (which is where you schedule a second trip out to look at a program after they've already interviewed you) they will pay for that stay too.

So when you get to the hotel, some nice residents from the program meet you in the lobby and take you out to a fancy restaurant and tell you all about why you should come to that program. You kind of have to take their information with approximately the same grain that you would a drug rep dinner, but it's still great!

The next day you go on your interviews, and a tour of the hospital, and then some other residents take you out to a nice lunch too! It's fun getting to meet all these new people, and see the different programs, but I have to say, after only 4 interviews, all the hospitals and residents are starting to run together, and if I hear "So do you have any more questions?" one more time I'm going to have a stroke. Some people I know are going on like 15 interviews, and I don't know how they're going to survive. Seriously.

My First Chest Tube!

Yesterday I got to put in my first chest tube!!!! This is a really cool procedure (and much coveted by med students the world over) - partly because it gives you the ability to really help someone in just a few seconds, and partly because they're pretty dangerous if you miss. If you're a little overzealous you can stick it in the liver, through the lung and into the mediastinum (where the heart and the aorta are), and even into the lung on the other side, all of which don't help the situation. You put in a chest tube when a person either has blood or air in their chest. In either case, the water or air is taking up room that the lung needs to expand, and the tube helps suck both of them out. If the patient has air in their lung (a pneumothorax), you'll get a rush of air when you stick the tube into the pleural cavity (where the lung sits, which usually has a negative pressure - if air rushes out, you know that there was a problem there). If they have blood in their chest, you'll get a gush of blood into the tube. In my patient's case, he may not have had any blood in his chest at all, as we didn't get any blood (or air, for that matter) back after inserting the tube. We think radiology may have overcalled it.

But at any rate, now I can say I know how to put in a chest tube!!!!

It's kind of a brutal procedure, and it's always nice when the patient is unconscious (or sedated well) when you're putting a tube in. You make an incision in the mid-axillary line (kind of under the armpit), after numbing the skin in that area. You can't really numb the skin and the muscle between the ribs completely, but you just do the best job you can. Then you stick in forceps, and open them and use them to make a hole in the muscle & cartilage between the ribs. It's very important to go right on the top of the rib, as a triad of nerves, arteries and veins runs right under every rib, and if you lacerate those, you give the patient a hemothorax, instead of fixing one. Then you grasp the tube with a bigger pair of forceps and stick those through the ribcage and into the pleural cavity. This is where you listen/feel for a rush of air, or get a lot of blood coming out of the tube. Then you stick the tube in until you feel resistance (the lung), and then sew it in place, and tape it VERY carefully to the patient's chest. Below is a Google image I found of dummies they have that teach you how to put chest tubes in.

We don't have any of those at Grady.

Here is a picture I found of what the tubes look like after you put them in. I didn't put in a pigtail chest tube, but that's more or less what the tube I put in looked like.

It was an exciting day!!!

On Call

On Tuesday night I got to take call, and I think it was my most fun day/night so far in med school. I got to see a bunch of operations I'd never seen before, and we had some good trauma. The general surgery residents cover call for the trauma service, so I got to see some normal general surgeries, that I should've seen last year on general surgery, like a below-the-knee amputation (BKA), which was SOOOOO cool....The residents here are so nice, and not at all like this guy:

They love to teach and let you help, so a great time was had by all. They were halfway through an APR (abdominal-perineal resection - when the patient has a necrotizing infection in their nether regions, and the flesh down there has basically rotted away, you have to go in and clean it all out, and try to find enough skin to stretch over what's left - a very complicated operation) when I got there, so I watched the end of that, and then after that we did the BKA, which I got to scrub in for, and help file down the end of the bones with what was basically a giant metal nail file. So much fun!

*****

The most serious case of the night was a patient who had a motorcycle accident, and basically not a scratch on him. He basically only had a bit of abdominal/LUQ (left upper quadrant) pain, and was joking with us....When we were cutting off all his clothes and putting a Foley (tube that goes in your urethra to your bladder - not very fun) in, he was like "This isn't at all like the Discovery Channel!!" He was a really nice guy. Unfortunately he turned out to have a Grade 4 (Grade 5 is the worst) splenic laceration. On CT, his spleen looked like hamburger, basically. Here is where your spleen is:

And this is what it looks like when it's on the scrub nurse's table:

The spleen above has a pretty minor laceration. So your spleen is what holds a lot of the cells that help pick the bad stuff (like viruses and bacteria and dead cells) out of your blood. So it has a VERY good blood supply, and holds a lot at any given time. It's also pretty important to have - people that don't have one are very susceptible to overwhelming infections later in life. And what's funny is that most people don't know whether they have one or not. When you ask a patient who has a scar over their spleen area if they had a splenectomy, many of them don't know what you're talking about. Kind of strange that so many people let surgeons dig around in their bellies without much concern over what they have left in there....So the spleen has a lot of blood running into/through it, and the blood carries hemiglobin, which carries oxygen, without which your cells can't live. This is hemiglobin:

In this case, our patient's hemiglobin level before we took him to the OR was 6 (normal for a guy his age/size would be 14-15 or so, and from 5-below, the patient could die very soon - usually from a cardiac arrhythmia, because the heart is starved of oxygen). Intraoperatively, it went down to 4. He was not doing very well. The reason we didn't give him any more blood was that he was a Jehovah's Witness, and they won't accept any blood products. Before we went to the OR we told him how dangerous this was and that there was a good chance he could die, and he was just like, "Can't you use those blood expanders?" No, real life is not like TV. So after we came out of the OR we talked to the family, but they said no. That was what he wanted. So there was basically nothing we could do. The next morning, his hemiglobin was 3. I imagine his blood was probably almost clear, having so few red blood cells left....His vasculature was basically full of normal saline instead of blood. He died that night.

******

Take home lesson: Jehovah's Witnesses probably shouldn't ride Harleys.