Week 5

Switching over to the trauma service required a little bit of adaptation, but I really like the team. The interns are really nice to me, the PAs teach a lot, and I feel like I'm appreciated for helping out. I take as many patients as I can handle, and I get a bit of freedom in deciding what I do. Though it's mostly floor work, I get to do things I think are exciting like taking out staples and chest tubes (really less exciting than it sounds). I've been taking care of patients with post-operative ileus, open book pelvic fractures, spinal cord injuries, and acute abdomen. I got to see an appendicitis from start-to-finish which was cool; I dictated the history and physical and scrubbed into the surgery to see the "lap appy." The only other surgery I saw was a peri-rectal abscess drainage. I'm learning a lot about tib-fib fractures and gun shot wounds and chest tube management. Interestingly, compared to elective surgery, trauma has way more male than female patients and a younger population. Despite the chaos, I like this service, and I feel like I'm contributing something unique to the patients.

Trauma Surgery Service

I switched to the trauma surgery service last week. It's very different from elective surgery. Obviously, it's unpredictable when patients come in. The most common traumatic injuries are motor vehicle and motorcycle accidents, gun shot wounds, stab wounds, and falls. But we also get appendicitis, pancreatitis, aortic aneurysm rupture, etc. Anything that comes into the emergency department with a surgical component ends up on our list. Some of the odder ones include man vs. animal diagnoses: car vs. horse, motorcycle vs. wild boar, falling off a horse, getting kicked by a horse (it's Fresno after all). Many of the injuries are severe and life-altering, and many involve orthopedics or neurosurgery: open book pelvis fractures, spinal cord injury, brain bleeds. Some patients are actively dying; others are admitted for 24 hour observation. Sometimes, we end up being a dumping ground for patients, and it sucks. Our census has no cap and it can get as high as 60 patients (how ridiculous is that? Spending 8 minutes per patient would take a standard 8-hour work day). The turnover is mindboggling; in a single day, we may discharge 20 patients and get 20 new patients. It makes learning very difficult and good patient care a challenge. It's a good lesson in ward management of an incredibly diverse and complicated set of patients.

There's less time in the operating room because everything is so hectic. Emergency surgeries happen when they happen, and people usually forget to contact students. Unfortunately these surgeries can often be the most interesting: stab wounds, bullets, ruptured bowel. Multiple emergencies can happen at once (multiple car crash) and more traumas happen at night. The whole situation is pretty unpredictable.

Poem: Untitled

Untitled

Cold hands, disinfectant pooling
along the creases of my palm
soaking into the index cards
flipped and unread
Nurse talking to the attending
in hushed whispers
and I wonder what I missed
Perhaps a monstrous spleen
or a bout of petechial rashes
or blood exploding out of her eyes
even though I was just there
with the little old lady
in no apparent (or is it acute?) distress
wondering why a cut that didn’t hurt
needed stitches
Now facing a senate of experience
awaiting my patient presentation
I realized I skipped family history
since cuts aren’t genetic, or are they?
and though I knew exactly
what I wanted to say
my dry mouth, irregular heart
held my tongue captive

Retained

Fortunately, a retained surgical instrument or sponge is a rare occurrence. But it happens. It might be easy to ask how something like this could possibly happen, but after seeing some high tension, rapid pace emergency surgeries, I realize how difficult it is to keep track of all the sponges and surgical tools on the field. There's no tolerance for such egregious mistakes, but the scrub nurses have their hands full preventing something like this.

Image shown under fair use, from cbs2chicago.com, original source AP.

PAs

This is the first rotation I'm on that uses a lot of "mid-level practitioners" - nurse practitioners (NPs) and physician assistants (PAs). I'm still getting used to it. I don't know officially what the background and role of an NP or PA is, but they are nearly physician equivalents: they can diagnose, prescribe (including controlled substances), treat, and first assist in surgery under the supervision of a licensed MD. I've found on this rotation that they act as ward residents. They take care of all the hospital patients while the MD residents are operating. They do the day-to-day "scut," see clinic patients, and act as continuity for the service as all the other members of the team rotate.

It's an interesting system. PAs do nearly everything that a resident (MD) does other than operate, yet their educational requirements are fewer and they do not do residency training. It almost raises the question: how much can non-MD practitioners do and what does being an MD really mean? Indeed, many medical conditions can be managed without having 7+ years of postgraduate training. But does 2-3 suffice? In talking to the PAs and working with them, I find them replete with practical knowledge: how to manage electrolyte replacement, how to put in arterial lines. But I think their training, method of thinking, and goals are fundamentally different from those of a doctor.

Surgeons

Surgeons have a particular personality. They like immediate gratification. Sew up a cut, drain an abscess, remove an appendix, resect a cancer. You do it, and the patient gets better. Surgeons take the diseases where you can see what's wrong, dissect it out, and deal with it. As a result, they come across as impatient and demanding. If you make them wait, if you do something wrong, if you don't prepare, they are unhappy. Surgeons are direct. They speak their mind. You know when a surgeon is unsatisfied or angry. They see things as black and white; surgeons are sometimes wrong, never in doubt. They're bold. They're arrogant. They see what they want. They get what they want.

After realizing this about surgeons, I understand a little better why they have their reputation among medical students. They come across as harsh, impossible to please, and imposing. They can be fickle and moody, and they will take their emotions out on anyone. Some days, they can be brilliant, supportive, dedicated teachers. Other days, they are best avoided. On this rotation, I sometimes feel that I'm treading a fine line; I want to engage as much as I can, but if I mess something up, no matter how small, I will regret it. It's not the greatest atmosphere for learning, but it's the one I'm given. Of course, not all surgeons are like this, and many non-surgeons are like this too. It's just what I've noticed on this rotation.

SFMS

I have a short article in the July/August 2008 issue of the San Francisco Medical Society (SFMS) Magazine. This came as a surprise. One of my FPC leaders convinced me months ago to write something, and apparently it made it into the latest issue. I completely forgot I wrote it and when one of my friends called to say her mom liked my article, I was flabbergasted. Here's a copy of the article; I'm not completely satisfied with it, but I never am with my writing.

-
From the SF Medical Society Magazine, July/August 2008.

Medicine as Muse
Craig Chen

As I begin my third year of medical school, I am bombarded by the wealth of stories on the wards. I journal my own struggle of adjusting to medicine outside the classroom, listen to patients recount captivating narratives, and weave a tale out of each history of present illness. This transition into active participation in the hospital rather than passive lecture learning has jump-started my imagination and motivation for creative writing.

As medical students, we have developed a keen intuition about when to jot down an attending’s clinical pearls of wisdom. The writers among us have simply transferred that instinct to identifying images, metaphors, emotions, and phrases that may trigger a story or poem. At the end of each day, I clean out the overfilled pockets of my white coat, and among the debris of the tuning fork and pocket pharmacopoeia, I find a note card jotted with ideas. Just yesterday, I had scribbled “organ donor asked how long for liver to regenerate; didn’t Promethius’s [sic] liver regen overnight?” With Greek mythology in mind, I realized that this campus sits on Parnassus, home to the muses, and the informatics system at UCSF is named after the Greek physician Galen. This juxtaposition of classical and contemporary medicine begged for a poem.

The ideas are replete, but finding time is the constant struggle. My interest in creative writing blossomed when I took workshops with Stanford University Stegner Fellows as an undergraduate. One of my writing mentors told me that it is easy to be a student who writes, but it is much harder to be a writer who’s also a student. To practice this art of the pen, I commit a block of time each day to writing. Whether it is reflection on topics from Grand Rounds on my daily blog or a sketch of a poem about going to a reservation with the Indian Health Service or a revision of a completely fictional short story, I force myself to craft something every day.

The greatest inspiration and motivation, however, come from my peers and physician-writers in the Bay Area community. Through remarkable vision and leadership, my classmate Mel Hayes organized a group of students who find writing the ideal vehicle for expression. Our hodgepodge collection of playwrights, creative nonfiction writers, poets, essayists, and storytellers has grown over the last two years; while it began as a handful of students gathering at cafes and apartments, it soon piqued the interest of many, from incoming first years to fourth years completing an area of concentration in the medical humanities.

Amazingly, faculty members were eager to support our budding writer’s group. Dr. David Watts, author of Bedside Manners, invited us to his office on Monday evenings to workshop our stories, prompt our imaginations, and discuss the nuances of narrative. Dr. Louise Aronson, whose short fiction has won national literary awards, organized an elective to formally recognize our time and work in narrative medicine. Even community writers such as Bill Hayes (The Anatomist; Five Quarts; Sleep Demons) join us in exploring both fiction and nonfiction as mediums for play and communication.

I’ve often had the skeptic ask me, “How can you possibly find time as a medical student starting on the wards to do any writing?” I make time to write because it’s fun. It’s therapeutic. Journaling is a way to debrief and reflect on that poor patient interaction, that frustrated staff member, that terrifying moment in the emergency department. Short stories allow me to experience situations from other perspectives, to think about how a patient interprets my actions, to listen to a family member interpreting. Poems help me capture a feeling, follow a curious train of thought, ask questions without expecting answers. Writing has value to me as well as those audiences who stumble upon my work.

This combination of writing and medicine is not new. All of us recognize that perennial symbol of medicine, the Rod of Asclepius, and most of us know the eponym refers to the Greek god of medicine. But few, I suspect, know that Asclepius is the son of Apollo, the patron god of music and poetry and the leader of the muses. The original classical Hippocratic Oath begins by invoking both Asclepius and Apollo. From afar, poetry and medicine seem to be discordant disciplines, representing the fuzzy humanities and the objective sciences. But as I enter this phase of my medical training, learning more the art than the science of medicine, I realize the Greeks might have gotten it right after all; that writing, like medicine, seeks to characterize and palliate the human experience.

Futility

I saw two very sad cases last week. The first was a woman in her 30s who had metastatic inflammatory breast cancer. The disease had infiltrated her spine so badly that standing for greater than 20 minutes puts her at risk for compression fractures of the spine (and thus, paralysis). There was nothing surgically we could do since the cancer had spread, and although she will start radiation and chemotherapy, she will die from her breast cancer prematurely. Surprisingly, her attitude about her disease and life was...cheerful. I can't explain it, and I won't try. I can't recall exactly what she talked to me about, but there was not a hint of melancholia. She understood her life in a way that I cannot yet comprehend.

On Friday, I scrubbed into a fascinating and involved surgery with the intention of removing a lung. It was breath-taking (excuse the pun). This was a young man in his 50s with squamous cell carcinoma of the lung. We began with a mediastinoscopy, an incredibly technical procedure to stage the lymph nodes of lung cancer. With a small incision above the suprasternal notch, we dissected into the pretracheal space down to the carina. The lymph nodes we sampled were negative for cancer, so we proceded to a thoracotomy, accessing the chest cavity to resect the cancer. This involved cutting the latissimus dorsi and serratus anterior, spreading the ribs, and seeing a lung in vivo, expanding and contracting. People go to Hawaii or the Grand Canyon or the Himalayas for a beautiful view; this was equally stunning. But then I saw the cancer, perverse, a purple angry splotch, hard as a rock. The anesthesiologist deflated one lung selectively and we went in, identifying the extent of disease.

The findings were shocking. The tumor had become so pervasive, it spread to the inferior pulmonary vein and into the pericardium. We got an intraoperative consult from another surgery attending, and he agreed with the seriousness of this disease. The cancer has spread too far. We could not resect it surgically. We thought we could cure this man, and now, after opening him up, we realized we can do nothing. Cutting out what we could would worsen his outcome, giving him only one lung without denting the relentless progression of cancer. So despite this four hour ordeal, we reinflated the cancer-infested lung, reset the ribs, sutured up the muscles, and left without changing anything.

Through this surgery rotation, I've seen immediacy of treatment: taking a scalpel to the problem and cutting out the pathology. But here, we've hit an impasse, unyielding, and I don't know how to negotiate the emotions, the feeling of futility. Everyone dies, and on a bell curve, some people are going to die young. Cancer is as reasonable a reason as any. But to cut someone open with the intent and belief that we could dissect away the evil, and to find that there's no recourse but surrender - I struggle to find the words. Yesterday's poem was such an attempt.

Poem: Restraint

Restraint

Like an octopus, the tumor grappled the lung
angry tentacles sliding along
strangulating its own lifeline
Like a spy, infiltrating the pink tissue
speckled black with soot and remorse
winding caverns, yawning chasms

Too late we arrived, too deep for dynamite
spelunkers hands, grime and blood
coprolalic caves echoing disbelief
ship abandoned on this reef

Time to go, he said, another book
for the library of unfinished dreams
the nightmares, the night sweats
the darkness beyond the event horizon.

Week 4

On Monday, I got to see my first total thyroidectomy. It was an impressive surgery. The patient had medically-refractory Graves' disease and her thyroid was huge, almost the size of iodine-deficiency goiters you see in third world countries. Through a tiny 5 inch incision in the neck, the surgeons were able to dissect out the enlarged organ. It requires a lot of precision since the thyroid has such a large blood supply, especially when hypertrophic. We also had to identify and isolate nearby critical structures like the recurrent laryngeal nerve and the parathyroid glands. It was quite involved.

I also got a hefty dose of routine general surgery including two breast lumpectomies for masses. On Wednesday, I scrubbed into three laparoscopic cholecystectomies (gallbladder surgeries) and when I was on call, we did a lap chole for a perforated and necrotic gallbladder. It was fascinating seeing the difference between scheduled elective cholecystectomies and an emergent one.

Conferences

There are a ton of conferences on this rotation. In pre-op conference, we review the patients who are getting elective surgeries to ensure that all the necessary laboratory work has been done. Two weekly noon conferences cover pertinent surgical issues such as ventilator management or work-up of gallbladder disease. There are several multidisciplinary conferences; in particular, in tumor board, we discuss the management of cancer patients with radiation oncology and medical oncology and in chest conference, mystery cases involving thoracic symptoms are presented. These are quite fun since they cross many different organ systems and disciplines. On Fridays, we have grand rounds where the entire department gathers for an often specialized talk, on CT scans or peripheral IVs or oral surgery for example. This is followed by morbidity and mortality (M&M), where all the services present the operations that happened that week and any complications involving those operations. Often, we will discuss in depth a surgery that had a complication to better understand why it happened so that we can avoid it, detect it earlier, or treat it better in the future. So there's a lot going on, though not much is aimed at medical students.

Kafka on the Shore

Oddly enough, on the busiest rotation so far, I've found time to read for pleasure (of course, I have yet to open up Schwartz's Principles of Surgery). Before Kafka on the Shore, I had only read a few of Murakami's short stories which I highly enjoyed. He's a prolific writer and I decided to start with this book, a "real page-turner, as well as an insistently metaphysical mind-bender" (John Updike). This was an excellent read. I think its impetus for me lies in its lack of boundaries. The book dares to go everywhere, pushing our conceptions of morality, identity, reality, and sex. Its pace and flow propel you through the suspension of disbelief, the magical reality, and help you connect with the strange characters of this book. Murakami also demonstrates a breadth of humanistic knowledge, covering aspects of literature, music, philosophy, and history. It accomplishes that very difficult task of opening up many riddles, offering few answers, and yet leaving the reader completely satisfied.

Image shown under fair use, from Wikipedia.org.

The Last Lecture

I read Randy Pausch's The Last Lecture which has gotten a lot of press over the last few months. A computer science professor at Carnegie Mellon University, Dr. Pausch was diagnosed with terminal pancreatic cancer despite a Whipple procedure (very similar to a patient we have on service right now). He decided to give a last lecture, "Really Achieving Your Childhood Dreams" and publish the book shown above.

I liked it. I generally have low expectations for these sorts of books (I associate them with "self-help" literature) but I was thoroughly impressed. He weaves humor, insight, gravity, and levity into an easily readable, short book that pays tribute to his family, his goals, and his influences. It's heart-warming, heart-wrenching, and charming with its life lessons. It's a good read.

Image shown under fair use, from cs.virginia.edu.

Poem: Skinning a Cat

Skinning a Cat

Honestly, I can’t think of more than one way to skin a cat.
The surgeon lets the idea steep a few minutes
and I ponder this feline plight of an idiom,
imagine the protest from the talking cats of Murakami.
What a cruel phrase to realize, but one that lost its garb
at two in the morning in front of this iodine yellow belly
seconds from engaging a scalpel, the surgeon pleasantly
asking where do you think the incision should be?
Out of all the cuts of sushi or carvings of turkey
I’ve had, I’ve never contemplated the heft
of that first slice, the resistance of the blade,
the history that drives us to set steel to skin.

Week 3

Week 3 had a few interesting OR cases. A young woman with previous abdominal surgery presented with a supraumbilical soft tissue mass which turned out to be a stitch granuloma (a foreign body reaction). Our complex case was a gastrectomy (removal of the stomach) for an unfortunate gastric cancer. That was an intense surgery, lasting 8+ hours. It was a good learning case though. After taking out the stomach, we called the surgical pathologist to take a look. I got to see how frozen sections were done and examined under a microscope. Unfortunately, the margins were not clear of cancer so the surgeons had to keep making wider cuts to get a cancer-free section. In the end, we made an anastamosis (connection) between the esophagus and the jejunum. The other OR case I had was a split-thickness skin graft for a patient with peri-anal hidradenitis, a severe dermatologic condition. Seeing how autologous skin grafts are harvested from the thigh and then implanted was very interesting.

When I was taking overnight call, I got to suture up a pretty severe finger laceration and put in a radial arterial line (my first one!). That was fun; it went smoothly and I really like using my hands.

At the end of week three, though, I'm feeling exhausted and sleep-deprived. No matter how early I go to bed, 4:45am is painful (at least it's 7am on weekends) and I am wiped after the 14 hour days. When I get home, I push myself hard to study. I don't have time for myself or for others; I can't explain how the blogging happens. Call kills me; on post-call afternoons after being up 30+ hours, I collapse in the student lounge. I think I've had a couple incoherent conversations with classmates who've walked in while I was napping. But during post-call mornings when I have fewer clinical duties, I feel strongly that my extra time should be used to do things we don't have time otherwise allocated for; I spent my last post-call morning talking to a patient with cancer and doing mostly psych-type conversation about mood, guilt, understanding, etc. And it's also tough that even post-call, we get grilled on difficult questions (what are the 11 Ranson criteria for pancreatitis?) and fatigue is not an excuse (to surgeons at least). It's good training but I don't think it's very sustainable.

I should say that I can't complain too much; one of my best friends at Johns Hopkins is doing her surgery rotation and she gets up at 3:30am every morning/night (it's even too early to be morning).

September 11

Lucky number seven marking the years after a fateful day and as is my wont, I confront the memory which lies in eclipse today, allowing us to grasp what we would never otherwise dare. How many of us discover gratitude in our existence? How many find respite in our heartbeat? How many even notice we are alive? September 11 could have been any building, anywhere, an act of maldivine temperament. Instead of being here, we could easily be looking down from above. But by stochastigarchy, we were drawn elsewhere, away from the epicenter. How many of us feel the aftershocks now? We’ve built this world out of free will, not brick, and some wolf will come and ravage it. Some say carpe diem, but I don’t think seizure saves us from arbitration. We need to shed our obsessive-compulsiveness, discard our anxiety about control, stop trying to micromanage details of our life because big things happen and we will be left insolvent of emotion, family, memory, material goods. What I felt this day seven years ago was helplessness, but it took me seven years to learn that stripping a person of everything still leaves hands, a head, a heart. When someone dies, her shadow lingers and her lessons persist. Even seven years later. No whisper is left unheard. 09.11.08.

Ex Lap

One of the most educational surgeries I've seen has been the exploratory laparotomy. This was done for the gunshot wound when I was on call (described in an earlier blog). Since there were multiple bullet wounds in the abdomen and back, we had to open up the abdominal cavity to look for bowel and solid organ injury. It was crazy. The surgeons did a large incision from the xiphoid process (bottom of sterum or breastbone) all the way to the pubis and opened up the belly like a cadaveric dissection. The surgeons "ran the bowel," looking in the small intestines for perforations. They dissected the large intestines away from the back wall of the abdomen (making it a peritoneal rather than a retroperitoneal structure) and looked at the stomach, pancreas, duodenum, kidneys, liver, and gallbladder. We found several bullets in the abdominal cavity and some bleeding, but otherwise it wasn't terribly bad. The entire procedure, which went from 2am-6:30am, was a beautiful teaching case in anatomy. I got asked ("pimped") a lot about nerves, blood supplies, anatomical landmarks, etc. but I learned a whole lot seeing everything in situ.

Week 2

Week 2 comprised of bread-and-butter surgery. I scrubbed into two laparoscopic cholecystectomies ("lap chole") for symptomatic cholelithiasis and acute cholecystitis. Laparoscopic surgeries are fun to watch since everything is done by camera and can be seen on big screens. Although now they are quite routine, laparoscopic surgeries are built on an interesting concept: can you manipulate tissue, remove organs, and dissect out vessels and nerves all using tools from the outside of the body under camera guidance? The patient really benefits because of faster recovery and smaller scars.

We also did an indirect inguinal hernia repair, a good lesson in male pelvic anatomy. I actually felt an external inguinal ring as if I were doing a hernia exam, which was good since I honestly avoid doing male pelvics as much as I can. But really, reading in a textbook about the inguinal canal is confusing, and seeing the open anatomy and its relevance helps a lot.

On the ward service, I took care of a poor patient that I really feel sorry for. This is a patient with no past medical history or risk factors who developed pancreatic cancer, one of the deadliest cancers. She went through a Whipple procedure, probably the most involved general surgery procedure and likely one of the deadliest as well. Her recovery has been really rocky, involving sepsis, liver necrosis, coagulation crises, and most recently, respiratory distress. I really hope she can get out of the hospital; every day, her husband is at the bedside and they are such kind, appreciative people. There's something important about being there for people during the toughest times of their life, even if you're just a medical student.

Poem: How to Win the Affection of a Beloved

One of my friends writes amazing form (structured) poems. Since I can't match her wit, I parody it. Here's a sonnet.

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How to Win the Affection of a Beloved

Begin the seduction with a poem:
“roses are red” or song lyrics you wrote
or a teen angst diatribe to show him
he is a castle and your love a moat.
Depart tradition; writers these days
court mother or dog or Vegas buffets
without clear iambs or rhyme or reason,
no nature imagery of the season.
Ignore conformity, make the sounds grind.
Invent a new stanza, go and define
modern day verse. It’s not a contrived art;
your rambling poem will capture his heart.
But at the end of these lines, I have found
I still defer to Shakespearean sound.

Trauma Activation

Trauma activations can be terrifying. When a trauma is called in, all our pagers go off (20 yo male GSW belly eta 5 min or 50 yo f mva gcs 7). If we're on call or on the trauma service, we drop everything we're doing and rush to the trauma bay. We put on a gown, hat, face shield, and gloves, ready for anything. About 10 people stand around the prepped bed, kits open and ready to go, a portable x-ray outside the room. When the helicopter or ambulance arrives, the patient is rushed in and immediately everyone descends. It's controlled chaos. As the emergency medical technician rattles off the patient's vitals and pre-hospital course, various people intubate, get vitals, attach monitors, attain vascular access, cut off the patient's clothes, talk to the patient if responsive, do a neurologic exam, examine the rest of the body, draw medication, and document. The head of the team, from either the Emergency Department or the Trauma Surgery Service, watches the flow and directs key activities.

The mantra of trauma resuscitation is the "ABCs" - airway, breathing, circulation. But in real life, these happen in such rapid succession that they seem to occur all at once. It's quite amazing; within 10 minutes, the initial survey is done, a CXR has been taken, the labs are sent, and the patient is off to the CT scanner. Already the decision is made whether the OR needs to be fired up.

When I was on call, we had several trauma activations. The first was a drunk man who was assaulted and found down in the middle of the road with a severe facial fracture. The second was a young man who had been shot with a pellet shotgun, about 12 bullet entry and exit points on the chest, abdomen, and back. During both trauma resuscitations, I was assigned the job of a femoral artery stick for blood gases and laboratory studies. In the second case, I also did the Foley catheter and chest tube. Everything happens so quickly it can be scary. On the first case, there was a little trouble intubating and when the patient's oxygen saturation started dropping, the attending grabbed the cricothyrotomy kit in case an emergency airway was necessary. On the second case, the room was prepped for a thoracotomy if needed.

Call

Call here is brutal; it's 30+ hours long with minimal or no sleep (I've been averaging 36 hours). The day begins normally at 5am for pre-rounding on patients. We round at 6, finishing up ward work before conference at 7:30 after which we go to the operating room or clinics. The day usually ends at 6 or so but on call days, we spend time with the overnight team. Usually, things are busy with Emergency Department consults, OR cases that weren't finished in the work day, and trauma activations (tomorrow's post). This can last all night; during free time, we see the ward patients to make sure they are doing well. If lucky, we can steal sleep in half hour increments in the call rooms (which are nice; they're personal rooms with a computer, bed, and bathroom with shower). The morning rolls around surprisingly fast and we're pre-rounding on our patients again and finishing up stuff by 10 or 11 (and dating our notes with the wrong date). Unfortunately, students are required to stay for afternoon lectures even post-call so I've been in the hospital until 5pm on my post-call days. The other thing about this rotation is that we come in on a lot of weekends to see our hospital ward patients; on Labor Day weekend, I had to work both Saturday and Sunday. It's a time-consuming rotation.

Hands-On

One of the more exciting parts of the surgery rotation is doing procedures in either the emergency department or the operating room. Of course in surgeries, we get to suture and assist. But I've been doing a lot of other fun things. A clinic patient had an abscess on his scalp so I did an incision and drainage, numbing up the area and then using a scalpel to reopen the lesion for pus to drain. I put a Foley catheter into a male (into the bladder to drain urine) which, while not the most glamorous of procedures, is easy for a medical student to do. It was also important because the patient had a hole in his kidney and all the fluid coming out was bloody. I attempted two femoral sticks for arterial blood gases, though I wasn't successful (I aimed too medially and hit the vein instead). And lastly on a trauma activation, I got to put in a chest tube for a pneumothorax, a decently complicated and scary procedure; we made a big incision at the fifth intercostal space mid-axillary line, used blunt dissection to get into the pleural space, and punctured it to put in a drain. Before putting in the drain, you can feel the lungs directly expanding during inspiration as well as the heart beating just centimeters away. All these hands-on procedures are fun, exciting, and scary; I'm not very good at them, but most simply take practice.

Fresno

Fresno is in central California, about halfway between San Francisco and Los Angeles. It's hot out here, really reminding me of Santa Rosa. We stay in apartments about 10 miles north of the hospital. The accommodations are quite nice: 2 bedroom, 2 bathroom in a gated area with swimming pools, an In-and-Out within walking distance, and a shopping mall close by.

The hospital feeds us well. There is a resident room with free breakfast and hot lunch every day (as well as numerous lunch talks provided by the department). It's a pretty nice hospital compared to SFGH where I'm always afraid an earthquake will send everything tumbling. I was also impressed by the UCSF-Fresno administrative and teaching building with its beautiful architecture, it's technological spiffyness, and it's spacious areas for lounging. So all in all, this is not a bad place to be.

Week 1

I think for this rotation, I'll describe things week-by-week. Much of the first week was occupied with orientation activities. The clerkship site director, though very direct ("surgeon-like"), seems to be supportive of medical students. We got a tour of the hospital and a quick reminder of how to scrub. There were pretty good lectures on radiology, trauma assessment, and shock as well as cardiothoracic conference, a morbidity and mortality discussion, a grand rounds on hyperbaric oxygen, and a resident presentation on gallbladder disease. I actually get a lot out of the formal teaching; the attendings here are good and focus on the clinically relevant, but they like pimping.

The ward service is made up of mostly elective surgery patients, but occasionally, trauma, burn, orthopedic, plastics, neurologic, oral and maxillofacial, pediatrics, and other patients wander through. It can be pretty hefty at times (on a 24 hour weekend call, we can admit 20-30+ patients, it's ridiculous) and we round at 6 in the morning so pre-rounding begins at 5 or so. I followed a patient with a newly diagnosed breast cancer and a patient who had a ventral incisional hernia repair. I actually scrubbed into that surgery where a mesh was sewn into the abdominal cavity to prevent protrusion of intestines.

We have two clinic days per week and I got to see a standard symptomatic cholelithiasis, a thyroid problem, and a mysterious neck mass (possibly disseminated cocci). I like the clinic setting as I'm more comfortable with the format and expectations, but we have to keep adapting to the logistics. I dictated my first two pre-op H&Ps which was incredibly stressful (I'm not sure why). It was the first time I ever dictated a patient but I later read the transcript for one of them and I think it went okay.