Surgery Clerkship Part Two

Patient (Pt) is coming in for colonoscopy and hemorrhoidectomy under general anesthesia. After lying down and going to sleep, the patient is rolled onto his stomach. The bed contorts with the whirring of engines to drop his legs down and lift his ass proudly to the Heavens. We pull his legs apart and place them into the anal stirrups. Two physicians (HPS and Brian) are sitting on stools between Pt’s legs for the show. Tape is applied to each ass cheek and then pulled around the bed for even “better” exposure.

The hemorrhoids are enormous and angry looking. They are each cut from the anus and the incisions sewed together. Brian, under the supervision of HPS, grabs the colonoscope. The c’scope is then fed into his rectum and maneuvered past the sigmoid colon, snaked around the splenic flexure, pushed along the transverse colon, and then descends down the ascending colon for a a good look at the cecum. No polyps or other masses. Everyone is happy. Brian pulls the colonoscope out of the colon, HPS leaves the room to dictate the operative note, and I begin taking down the drapes. Brian takes off his sterile gloves, gown, and plastic face shield. I lean over the patients back to release a clip holding the drapes in place and my weight compresses the patient.

PHBLLEEBBTHURUUUURP!

During a colonoscopy, air is pushed into the colon to inflate it for “exposure”. As the colonoscopy is finished, this air is typically sucked out so as to leave the Pt as comfortable as possible when they leave. Brian forgot to do this.

The shit sprays everywhere. On his cheeks, his eyelids, his forehead, arms, and neck. It turns his blue scrubs brown. The anesthesiologist screams. Brian is on the other end of the room, having kicked himself reflexively from the patient on his sliding stool. In fact, he’s still coasting towards the far wall as we watch him panic, trying to find a poopless place on his body to wipe away the poop on his body. He can’t find anything. The panic sinks in its teeth.

“Somebody HELP ME!” But we’re the ones that need help. We’re twisted in knots, fighting for gulps of air as we struggle against the laughter. We’re not even human right now: the laughter owns us. The patient begins to wake up. Hearing the commotion, HPS reenters the room.

“Oh GOD!” And HPS leaves the room to dry heave in the hall. It’s been 40 seconds since my last breath and my chest is starting to spasm. I can’t tell if we’re even making noises anymore or if we’re all quietly dying of laughter.

The scrub nurse walks over to Brian and, afraid of the hand-off, throws a towel at him. He begins to wipe himself clean. The patient is awake now with the embarrassment that only a person with his asshole winking at a room full of laughter can ever truly know. Brian has wiped his face and is now storming to the wash room to clean himself. He walks by the head of the bed and the patient pieces it together.

“Oh, I’m so sorry if I pooped on you.”
Brian manages an “It’s okay” before walking out.

From the halls, we can hear the heavings of HPS start up again.

Surgery Clerkship Part One

*I wrote the following for friends and family a long time ago. Thought I’d share*

My third year is fractured by discipline and geography. Watch me as I hurdle across the great states of Pennsylvania and New Jersey through Surgery, OBGYN, Psychiatry, Pediatrics, Family Practice and Internal Medicine. I plan on writing once/twice per rotation.

For now, I’m beginning my third month of Surgery in Pittsburgh.

Who knows for certain, but odds are that I’m going to cut people for a living. Others want to be physicians in order to help people and that’s great. I’m just looking for stabbings minus the jail sentence.

We begin with Trauma, a painfully slow field punctuated by bursts of exhausting speed like the sprintings of the obese. From 6am to 6pm, we waddle the four corners of the Trauma ICU tending to the most serious cases from the last week. It takes 12 hours to see 15 patients for several reasons, though I am unaware of any good ones. Attending Spanish Physician has sleep apnea. This causes him to fall asleep standing up at times in the middle of rounds while someone works up the nerve to tactfully clap their hands. Attending Scottish Physician never uses two words when ten would do. He has held court on the following:

1. George Washington’s teeth
2. The French and Indian War
3. Mussolini’s v. Hitler’s fascism
4. Why flying airplanes is so difficult
5. Things back in his day

Imagine it: twelve hours every day spent on two hours of real work. You can’t escape. Attendance is mandatory. “If you ask him a question, I sear to God, I will kill you.” So I don’t ask questions. I just stand there, eyes glazed over, praying for a midday TRAUMA ALERT: 30M 20FT FALL FROM TREE +LOC HEAD LAC ETOH 5MIN ETA VIA GRND.

Drunks in trees. All the time.

I like responding to traumas because I am an important member of the Trauma Team. I am make-sure-they’re-naked guy. I stand poised, trauma scissors in the air with blades just slightly opened, waiting to cut away your dignity. You’re a trauma, you’re getting naked. No negotiation.

“Are you cutting my dress?”
“Yes, ma’am. We have to check you for injuries.”
“But I just fainted!”
“Yes, ma’am. But you fainted in a car. That makes you a ‘trauma’. Please stop moving your head; you may have a broken neck.”

Because it is hard to schedule traumas, there was little time in the operating room and the majority of this service felt like ER with knives. Fun, but glad when it ended. After three weeks, I moved on to the Colorectal surgery service.

You would never guess it, but poop surgery is great. The incisions are huge and the anatomy is straightforward, so it’s easy to play along. You take people that are absolutely miserable with constant nausea, vomiting, diarrhea, fevers, etc who can’t remember what it feels like to enjoy a meal. You cut out their colon: cured. Thanks to preoperative bowel preparation, there is actually very little stool (or succus) during surgery, which is fortunate when you’re a 250lb ex-football player turned Head Poop Surgeon (HPS) that vomits at the sight of it. During an operation where the small bowel was being cut in two, some green stool began to leak from the lumen.

“Oh my God, I’m gonna throw up. IMGONNATHROWUP! Brian, get it away! GETITAWAY!” HPS stutters back from the table, dry-heaving.
Brian wipes away the small amount of stool with a lap pad as those not twisted in hysterics stare on in horror at HPS’s reaction.
“I hate that. Oh, I hate that. Okay, let’s finish.”

Poop surgeons don’t like to be called “poop surgeons,” by the way. It’s no use explaining to them how funny it is. They just don’t get it.

Much has been made of “pimping”, the art of harassing medical students with questions in order to expose their ignorance. This is often described as being malignant. This has not been my experience. If anything, I have wished aloud to be asked more questions in order to better learn what is and is not important and to have a chance to show that I am studying in my spare time. Barely touched on Trauma, Colorectal gave it a good try. With mixed results. Here is a smattering:

“Christian, what is the social muscle? ”
“The tongue, sir?”
“No. It’s the anal sphincter. If it doesn’t work, you have no social life and no home. Watch a bunch of monkeys. They hang out together, all poop, and then they have to move. That’s why monkeys don’t have houses.”

“Christian, what are the indications for surgery?”
“Hemodynamic instability.”
“That’s a trauma answer. This man is having his colon removed, so that’s a pretty stupid answer for this man, isn’t it.”
“Sorry, sir. Any condition that has been refractory to medical management for which a surgical solution exists that is not otherwise contraindicated.” To myself: booyah.
(Pause). “Wrong. Um, what’s the most important thing to remember when irrigating the abdomen?”
“To suck the fluid back out, sir?”
“Um. Wrong. It’s to not use too much. Okay smart guy, what’s that?”
“The uterus, sir.”
“Good.”

“Christian, why did Brian call you ‘topher’?”
“It’s my nickname. It’s short for ‘Christopher’.”
“So you’re name isn’t ‘Christian’?”
“No, sir.”
Brian: “We told him we’d kill him if he ever corrected you.”
“Oh. Good.”

Playing the role of the good surgical student slowly earns you privileges in the OR. I have the privilege of cutting sutures with the scissors. I have the privilege of holding and pulling things. At the end of the case, I have the privilege of using staples to close the skin or use sutures to close a small hole. Execute each of these without error, and you are praised. As much as I gripe about being compared favorably to a seven-year-old with appropriate motor skills, the simple “nice job” can make your day. I was graduated to eight-year-old after being offered the scalpel to make the first incision for a case. This was no nick, but instead went from his sternum to his pubis. When HPS made it clear that I was going to make the cut and the he was not joking, the surgical masks in the room nearly popped off from the slacked jaws.

My post-op juice box never tasted so sweet.

All for now, topher.

P.S.
Trauma Lesson: Car + anything = trauma = naked = rectal exam.
Colorectal Lesson: Poop kills.

Just about two years

Like analogies, tides come in waves.  I’ve been writing a lot of them lately and trying them in conversations.  If there’s no one around, I try them in made-up conversations.  This is the charitable way to say that I’ve been talking to myself more and more.

This is an outlet problem.  I’m nervous for something.  It’s either too big, too important, or too scary to handle myself.  But coming anyway.  It was college, when I wrote a journal every day for two years without fail.  Then I stopped.  It was medical school, when I started RWT.  I stopped two years ago.  Now, it’s the next biggest thing that happens in your life.  Before the next thing.

And I’m talking to myself.

I went to tell you, someone, anyone about it. In a few days, I will be engaged.

But right now, I’m wearing an ugly sweater.  She wore it a few nights ago.  Tonight, I want to write two of the most outrageous stories form my trip through Asia.  I want to write about my time in South Africa and the month I spent in Ecuador.  But what I’m really thinking about is these backward buttons.

I hope every guy learns it eventually*, but the buttons on female clothing are opposite to ours. In the past, men were dressed by maids.  Male clothing has buttons were women are used to them – on the left.  Thinking back on times where I’ve needed her to fix a cuff for me, I think about how this intimate and nice thing is because of her practiced fingers.

She’s left for the coast two days ahead and we’ll see each other tomorrow.  It’s hard to focus.  It’s hard to think that the holiday cookies I’m eating or the champagne I’m drinking is anything but a way to blunt something else.  Looking for a way to focus on what I have to write tonight, it’s becoming easier to understand that this too-tight and oh-so-perfectly ugly christmas sweater is more than a writing tool.  It is what I need to understand about myself at this moment.

Erik Erikson is about the only thing I liked about Pediatrics.  He had this theory about the stages of development through which everyone must pass.  If I’m figuring out something tonight, I hope it’s everything.  I’ve been looking for the first two teeth to click correctly, finally, so that this whole thing zips together and closed. I’m looking back at my life and seeing how it falls into what he described.

Looking back at the stages, I remember them.  I wrote through them.  And it’s finally making sense to me why my writing has come and gone so many times even when I wished it stayed.  It makes sense to me why I thought I was going to be a psychiatrist.  It makes sense to me why I’m writing now.

I need to work through this.  When I came to the Caribbean I had my last and perfect opportunity to define myself.  And now that I have, I’m ready for the next thing.  But I have to work through it still.

Thank you for being patient, for thinking I’d write again, for caring that I disappeared, and for reading at all.

Cheers, topher.

*I first discovered this at a Goodwill.  I was looking for cheap pants for the new school year.  I found this pair of beige corduroy pants that fit perfectly.  I didn’t recognize the manufacturer nor did I know what “size 8” meant, but I wore the hell out of them just the same.

“It is human to have a long childhood; it is civilized to have an even longer childhood. Long childhood makes a technical and mental virtuoso out of man, but it also leaves a life-long residue of emotional immaturity in him.”

— Erik Homburger Erikson (1902-1994)

Hello Again

I had promised to do this a little while ago.

Grenada is in my thoughts again. Since leaving it as a transfer to Drexel, I have had an amazing time as a 3rd and 4th year student, dabbled in the world of pick-up artists, applied for and failed to match into a Plastic Surgery residency, traveled to Ecuador for a month to learn Spanish, traveled to South Africa for shits and giggles, filed a patent on a medical device to help hospital workers wash their hands more often, worked on a few more books and projects with the folks over at First Aid, become a research physician at a prestigious institution, met my future wife, and I have manage to put a ring on her finger.

In April, I’m headed back to Grenada as a Visiting Professor of Anatomy and I am excited to see what they’ve done with the place.

In my absence, transferring and quitting have been the most popular topics on this blog. I am really happy that people have found a place to discuss both. I am disappointed in myself for not finishing the “transferring” section of this blog and giving it the attention that it deserves. At one time, I thought I might finally write a book about it. But for now, I am building a new site for that topic which will do the issue justice.

Still here.  Still thinking of things to write about.

Cheers, topher.

Missing This

I write to you now, briefly, as someone who has dis- and then re- appeared.

I have successfully completed the final two years of medical school.  Most people view the two clinical years as the most interesting years of medical school.  I think I agree with that.

I have gone through the process of applying for a competitive specialty.  I have gone through the match.  I have landed a job.  And I have thinkings about all of it which I’d love to share.

I probably will.

For those of you that still check back to this space, that still wonder “what the hell happened?!”, this is for you.  What do you want to know?

Whatever you suggest, I will address.  Be my impetus.

I can’t wait to start – topher.

Keeping busy.

I am still writing.  I have a bank of stories that I’m going to release after the Match about everything that has happened over the last two years.  With all my free time since ignoring the internets, I’ve been able to do other fun things.  This is one of them.  Also, this is my face and my voice.

As far as the cube goes, I bought one in November of 2007 and went to Lars Petraus’ website. 

1. Step 1 – Build a 2x2x2 corner
2. Step 2 – Expand to 2x2x3
3. Step 3 – Twist the edges (I use one algorithm from this)
4. Step 4 – Finish 2 layers (I use one algorithm from this)
5. Step 5 – Position the corners (I use one algorithm from this)
6. Step 6 – Twist the corners (I use three algorithms from this)
7. Step 7 – Position the edges (I use one algorithm from this)

It took my about two days to figure out my first solve (basically following the website move for move).  It was another week before I could solve it without looking at my cheat sheet of written algorithms.  Another week before I was sub-5 minutes.  A week later it was 3 minutes.  I spent about a month hovering around 90 seconds and have been stuck at 45-60 seconds for the past three months without any real improvement.

I have no plans to solve it blindfolded, but appreciate all the people that tell me they won’t be impressed until that happens.  You people suck.

Don’t let the books swallow you, topher.

Brevity is the Soul of Wit

A friend asked in a letter,

Still thinking of being a people doctor? have you switched at all more toward research?

The question has been on my mind a lot, and I guess it had built up enough pressure. My response was disproportionate.

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Therefore, since brevity is the soul of wit, and tediousness the limbs and outward flourishes, I will be brief:It’s funny. I’m applying to transfer into a US medical school pretty soon which means a handful of personal statements. And for all the writing that I’ve done, I still have no idea how to do it correctly. I’ve tried to get to a point in my life where I understand who I am and why I do the things that I do, but I’m just not there yet. Which is fine, it just makes it hard to convince someone else that you’ve got the reigns in your hand, so to speak. It’s always ugly, but whenever you can’t prove or demonstrate something positively, there’s always the reductio ad absurdum. As far as I go, it’s the best I can do.

As it stands, I’m still curious about damn near everything. I have a folder called “million dollar ideas,” one called “essays” and one called “research.” I see problems everywhere and I love obsessing over solutions, and all of these interests pull me deeper into medicine. It’s just so deep and so wide, there’s enough room for anyone to lose themselves or find themselves. That’s why I’m here, I guess.

I’ve always joked with people when they ask me, “So why do you want to be a doctor?” My typical answer is that I’d be too bored with anything else, and that’s a half truth. I only see the rest when I work backwards:

I’d love to be a surgeon, but the malpractice risk and insurance along with dropping pay are off-putting, so I guess I want to be paid well according to my skill and don’t want to enter a field where that may not happen. I’d love to be a pathologist with all the time to write, do research, dissect. But I’d miss the patients. I’m reluctant to admit it, but I would miss the satisfaction that comes from someone you’ve treated thanking you with their eyes. Internal medicine is appealing for the challenge of trying to know everything about everything, but the patient exposure is above what I’d like and the pay seems off the worth. I guess I want to see people, but not all the time. I want to write, I want to teach, I want to cut, I want to cure, I want to be paid what I’m worth and I want time to enjoy the fruits and to share it with a family. I have two years left to figure out if anything fits those criteria, but from here things still look pretty messy.

I still don’t know what I’ll end up doing, but I hold fast to the belief that something fits. I want to transfer because I feel like I’m running out of time to make that decision cleanly. More exposure, more people, more resources and all of it right now would go a long ways to convincing me that I’d seen the field, taken stock, and decided on my future. If it turns out that there’s some unanswered question that I think I can tackle and is worth my life’s efforts, then I want to be exposed to it. I worry, a lot, that I’ll miss that opportunity if I stay with my current school.

The facilities, the people, and the open doors of a US medical school would be an embarrassment of riches for me at this point. In the time that I’ve studied with less, I feel like I’ve used everything available so that now, finally, I know how valuable those opportunities are and I’m ready to make the most of them. I’m praying for the chance.

Until that happens, I won’t know if it’s people or research.

O Tell Me The Truth About Love

Seen on the R subway line between Atlantic-Pacific and 7th street.

When it comes, will it come without warning?

Just as I’m picking my nose?

Will it knock on my door in the morning?

Or step in the bus on my toes?

Will it comes like a change in the weather?

Will its greeting be courteous or rough?

Will it alter my life altogether?

Or tell me the truth about love?

I still don’t know what “it” is. Any thoughts?

How to Prepare for the USMLE: How Early Should I Start?

I have received a version of the following email half a dozen times in the last few weeks concerning when in the first two years of medical school it is best to begin preparing for the USMLE. Here is one response.

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Hello,I wanted to thank you for that information regarding studying for the BEAST!. It is well informed and I loved the reasons behind your study schedule. I am going to start my first term at SGU this coming august. With your experience the past two years is there any advice that you can give me. Does using first aid while studying for exams help to prepare for USMLE. Is it too early to even use it as a reference. Also doing well in the classes help drastically on your performance in the exam. Did you find that having done well made you recall alot of things that you found on the exam or is the details very nitty that it isn’t and needs to be refreshed within the 6 weeks. Wanted to know if it would be a wast of time to use the First aid as a supplement and note margin for my regular classes to be familiar when it comes time too kick but those 6 weeks. Again, thank you for the information.

Knight

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Hey Knight.As far as advice goes about starting early, I have only this: I couldn’t do it. It takes a certain amount of pressure and dread to study effectively for the USMLE, and that’s not just going to be absent, it’s going to be appropriately focused on your other courses. I’m sure you could annotate the FA during these classes, but you’ll soon find that the breadth and depth of your SGU classes will simply dwarf what’s in the FA. The best advice I could give is to work as hard as you can for as long as you can in your classes. While the game of getting A’s isn’t all there is to your education (and you will feel at times that you are learning stupid things to do it), I can think of no better long-term preparation for the USMLE. Those members of my class that have scored the highest were all very strong students from front to end in Grenada and not for being especially intelligent, but instead for their consistent hard work.

The extra mile here is tutoring. I tutored Anatomy, Biochemistry, Neuro and Physio. In this way, I had a full year’s exposure to each topic instead of the four month term. This was invaluable. What many people found while studying for the USMLE, I discovered in tutoring: it’s only the second time around that all the connections fall into place and the interrelationships become intuitive. I was a much stronger student for it.

In a nutshell: don’t buy a First Aid until it’s time (around 5th term, I’d say), do your absolute best in every class, regardless of how innane the material, and tutor with a friend for every class that you can. That, if done, should fetch you a fantastic score.

All the best, topher.

Back from Vacation

Finally, I am back in the States. I brought back with me custom-tailored shirts, shoes, and suits, a tan (no tattoos) and a few stories. It’s going to take me a while to get back in the swing of things, what with the big move to New York just around the corner.

One great thing that happened while I was gone was the posting of a preliminary errata list by the First Aid folks. After looking through the pdf, I’m thrilled to say that we have been thorough: fourty-three of the the fifty official errors were already listed here. Whether or not we were responsible for submitting them first is unclear, but at least we’re catching them. Five of the errors were added from readers of this site (thanks guys).

I’m going to spend the next few days going through what everyone has submitted and then updating each section, as well as the word documents. I don’t anticipate there being another major update before the July 15th deadline.

For those students asking about my transfer status, the schools to which I applied, etc.. I do not plan on addressing those topics until mid-June. Sorry to put it off.  The remainder of this week will include a few stories from Asia and a few miscellaneous thoughts about the USMLE before I put it behind me.

It’s good to be back.