Lights out!

Have you ever wondered what would happen if, while you were having surgery, there was a power failure? Well, as of today I can tell you not to worry--hospital emergency backup power systems work beautifully.

One more thing to worry about

Historically, one of the biggest worries in the operating room was fire. Early anesthetics, although effective, were highly flammable and it was not unheard of for surgical cases to end with fire or even an explosion. Although modern anesthetic gases are not flammable, there are still fire hazards in the modern O.R. such as electrocautery and lasers. My anesthesia textbook, however, has made me aware of an unexpected additional source of danger.

The bacteria that live in the human gut produce both methane and hydrogen gas, both of which are highly combustible. The textbook warns of the risk of a bowel puncture leading to intestinal gas fires or explosions. I've been diligently asking, but I have yet to find anyone who has actually witnessed such a thing. Still, I plan to keep an extra bucket of saline handy the next time we take out someone's appendix.

Projecting competence

Sometimes one of the harder things to do during medical training is projecting a reassuring sense of competence while performing a procedure that you have only done a few times before (if ever) and may not be well-trained in. You may not, in fact, be competent. But it's important not to freak the patient out. For example, I haven't started a lot of IV catheters yet. Today I did one for a patient whose spouse expressed concerns to my resident about the med student performing the procedure: "you're going to let HIM do it!?" That helps you relax and stay focused, lemme tell ya. Fortunately, my resident was great at "explaining" what I was doing (i.e. giving me a heads up before I made a mistake), everything worked out great, and patient, spouse, and med student all ended up satisfied and in no pain.

Things are not ever thus, however. A few months ago a guy came in with an interesting hand laceration. Staff said that I might get to sew it up myself, but the patient tended to be squeamish and we'd have to see how comfortable he was. So I put on my best medical-scholar-contemplating-the-diagnosis face, buttoned up my short white coat, and tried to project cool, confident competence to both the patient and my attending.

Unfortunately, the front pocket on one side of my white coat was loaded with reference books and instruments, pulling that side down, and when I buttoned my coat I failed to notice that I was one button off. Stood there in front of the guy the whole time with an oh-so-serious expression on my face while looking, well, not entirely competent. As things turned out, I didn't get to do any sewing.

Hurricane Dean

Next year Lady M and I are planning to spend some time on the Gulf Coast of Mexico--I for a medical rotation, she for a vacation rotation. We'll be visiting The Former Hawkeyes, our good friends who spent time here in Iowa for fellowship training and are now inviting us to their home in Mexico for my training.

Their home is Veracruz, which is currently in the news as the point at which Hurricane Dean is making second landfall in Mexico. I just heard from them via e-mail, and they report that they're fine. We're worried, however, since their house is quite near the beach. We're all sending our best wishes to los hawkeyes anteriores as they weather the storm.

A new perspective

I've scrubbed into my fair share of surgeries thus far in med school, but I've always been standing down by the surgeon-generated hole in the patient. Now, on anesthesia, I'm up at the head of the bed, and it's a different perspective in more ways than one. When you're controlling someone's airway, or bag-mask ventilating a patient whose diaphragm is paralyzed and is depending utterly on you for their oxygen, it's a whole new feeling of responsibility. Anesthesia residents are some of the coolest cats in the hospital, and I'm starting to understand why.

Something for the pain

Tomorrow I start a two-week anesthesia clerkship. I've been looking forward to this--we get to be part of the anesthesia team in the OR, and we'll get lots of info about the various drugs used, airway management, and so on. Maybe I'll even find out whether it's anesthesia or anaesthesia.

Flash! Bang! Offline!

Last night our faithful old computer gave up the ghost in spectacular fashion. Handcrafted years ago by Big M from a car battery, some war surplus vacuum tubes, and the brain of a squirrel floating in a cereal bowl full of saline solution, it ended its career with an impressive audiovisual display. It looks like this weekend will involve some computer shopping.

A Sub-Intern's fond farewell to the Siouxland Medical Education Foundation

I came to Sioux City to do Sub-Interning,
Family Practice, a full month of learning.

My day starts with hospital rounds up on Five
Attempting to keep all the patients alive.

Now one of our patients is having a baby!
Will I get to deliver? The answer is... "maybe."

But wait, what's that sound? Could it be my pager?
There's a case of chest pain in the ER, I'll wager.

Later, overnight call keeps us up 'til all hours.
The next day nurses wonder if the Sub-Intern showers.

And so these four weeks have flown by much too fast.
(Will the knowledge I'm trying to memorize last?)

Now, sadly, it's time to be saying "adieu"
To the wonderful folks of the city named Sioux.

Where's Ben-Bob been?

Astute readers (as well as those with too much time on their hands) will have noticed that I haven't posted for several days. In fact, this has been my longest hiatus since starting this humble blog, a side effect of long and highly educational hours in the hospital and clinic (of which more later).

In the meantime, there's a rumor going around that in a past life I may have been implicated in some musical productions. There have even been some requests that perhaps examples could appear right here on this very blog. Unfortunately, being on the road as I am right now I have limited access to the archives, but when I get back to Ben-Blog Mission Control I'll see about uploading some groove.

On-call Liveblogging: Baby, baby, baby...baby!

Whew. Four deliveries last night. Little cuties being passed around, placentas bouncing off the walls. A great day! (Well, night/day/night/morning, really.) Even managed to get a couple of hours of sleep. But we were looking a little ragged on postpartum rounds this morning. We're keeping an eye on the board today--right now nobody's in labor.

At this point I'm about 77 hours into my long march of duty and call, with about 30-some hours left to go. I'm heading up to the nursery now.

On-call Liveblogging: Calm before the parturition storm

We now have four women in labor. I'm hunched over a computer, quickly reading up on particulars relating to each patient. Things are going to get very busy here very soon.

On-call Liveblogging: Pregnant with anticipation

It's Saturday afternoon and we've got three patients in labor. (One of them just asked me if I would be delivering her baby!) If I'm going to catch any babies, it'll probably be soon. Of course, they'll all probably go at the same time....

On-call Liveblogging: Seen and heard

Overheard at the L&D nurses station:

Nurse A mentions that she doesn't like spicy food. Nurse M is passing by, and he says "liar, I know that you like hot things." Nurse A replies, with a sweet smile and without missing a beat, "No I don't--that's why I like you."

Strong work, Nurse A.

On-call Liveblogging: Waitin' on my baby

This post is comin' at ya live from OB call. I've been on-call or on duty since yesterday (Thursday) morning, and I'm on straight through until end-of-day Monday. My mission? To deliver a baby. I did a few on my OB/Gyn rotation last winter, but I've been hoping to get some deliveries here in Sioux City. Unfortunately, I'm having no luck at all. As soon as I walk onto the Labor & Delivery floor, everyone's contractions stop. A couple of days ago I got within about 90 seconds--I was gowned and gloved and getting into position, when baby's heart tones crashed and the attending ran into the room, ordering emergency equipment. Both mom and baby did fine, but it wasn't a delivery for a med student.

So wish me luck and think fecund thoughts on my behalf.

Operating Theater

Traditionally, surgical operations (and anatomical dissections) were often performed in amphitheater-shaped rooms where rows of medical students and other interested parties could observe the proceedings. Modern operating rooms, however, do not have seats for observers. I've been in some of the old operating theaters, but have never seen a procedure performed in one.

Yesterday I was invited to watch a Cesarean section that had the potential to be a somewhat complicated case. I've scrubbed into and assisted with a fair number of C-sections, but this one turned out to be a new experience for me. This case took place in a small O.R. When I got there it turned out that plenty of people were already scheduled to be in the room and there was no room for a supernumerary medical student. Instead I was directed to a small door hidden behind the main swinging doors to the surgical area. Slipping inside, I climbed a dark, narrow set of stairs. At the top was a glass-enclosed gallery looking out over the O.R., equipped with a row of chairs. I was alone in there, able to observe the entire procedure from overhead.

I had never watched a surgical case from this perspective. It was very strange, since most of the participants never noticed me up there. Of course, they also don't notice you when you're watching a remote video feed on a monitor in another room, but this was different--the patient, lying on her back before the operation began, was one of the few people in the room to see me behind the window a story above her.

And I got a surprise, myself. As I watched the anesthesia team, the surgical team, and the pediatric team perform their respective roles, I realized that I knew what everyone was doing. Not too long ago this complicated procedure would have been a largely incomprehensible jumble of gowned operatives, beeping equipment, and subtle maneuvers made by sterile-gloved hands. But yesterday not only could I follow along, afterwards I even discussed the surgeon's technique with one of the other physicians. Maybe I am learning something in medical school, after all.

Dinosaurs in your ears

A common and frustrating scenario for medical students goes something like this: you go into a room to examine a patient. During the exam you find something, say a heart murmur. You go out to present the patient to staff, saying "Mr. So-and-So has a Grade II systolic heart murmur." Then the two of you go into the room, where the doctor examines the patient while you stand awkwardly in the corner. The patient asks "Doc, do I have a heart murmur?" The doctor listens--and assures him that he doesn't. Now, medicine is often as much art as science, and physical exam findings can vary from observer to observer. But generally speaking, the med student ends up feeling (and looking) kind of, well, dumb.

So yesterday I'm giving a five-year-old boy a preschool physical. He's squirrelly, and I need to get him to sit still so I can get a good look in his ears. (Accidentally administering a deep penetrating brain injury with an otoscope to a five year old during a routine physical is considered extremely poor form; it would probably even affect my grade for the rotation.) So I lean close and whisper "I'm going to see if there are any dinosaurs in your ears. If you sit real still you might be able to hear them!" Sure enough, he sat up straight, stopped squirming, and I got a beautiful view of each tympanic membrane.

After finishing my exam I went out to talk with the doctor about him, and then we came back in together. As soon as the doctor picked up the otoscope the kid smiled, tilted his head to present an ear, and excitedly asked "are there any dinosaurs in my ears?" No, the doctor assured him, there aren't any dinosaurs in your ears.

While the doctor was busy, I stealthily grabbed the clipboard with the physical exam form and scribbled "no" at the beginning of the line where I had written "dinosaurs in ears."

Nuptials, Nostalgia, and Nuclear Submarines

Today finds me back in Sioux City after a whirlwind trip to the Pacific Northwest for the wedding of Lady M's sister in Port Townsend, WA. (Apologies to everybody in the area that I didn't call or visit--I was there for less than 48 hours.)

I left on Friday afternoon following noon conference, flying out of Sioux City's Col. Bud Day Field (which bears the rather unfortunate three-letter airport code SUX). My connection was in Minneapolis-St. Paul, and as we descended over the downtown in our Canadair Regional Jet there was much rubbernecking as the passengers tried to catch a glimpse of the collapsed I-35 bridge. It wasn't visible from our angle, which is just as well since everyone rushing over to one side might have unbalanced our little jet. On the flight out, however, the site was fully visible from the air.

I got into Sea-Tac late that evening, rented a car, and set out across the Tacoma Narrows bridge for Port Townsend on the Olympic Peninsula. For most of the drive there wasn't much to see in the dark except at Bremerton, where the three-quarter-full moon silhouetted the US Navy warships moored there.

The next morning I awoke to find myself at a lovely Victorian bed and breakfast on a bluff over the ferry dock with a magnificent view of Admiralty Inlet and the Olympic Mountains. After breakfast most of the morning was a flurry of wedding preparations. The bride's party was getting ready in our rooms, so I did a little ironing and otherwise tried to stay out of the way. The ceremony itself was very nice--simple and brief, with an appropriate amount of crying. We had perfect weather, which made the backyard garden reception all the more enjoyable. Great food, including oysters on the half shell, although apparently Oyster Guy made a pass at both Lady M and her brother, Big M. And, although I haven't made a formal toast for a while now myself, I got to vicariously relive past toastmaster glories by huddling with Lady M's other sister as she prepared her Maid of Honor toast to the bride.

But no wedding goes off without a hitch or two. Towards the end of the reception we learned that Big M's keys were in a car that had already left. And it was a cliffhanger: the folks with his keys were heading to catch a ferry--if they made it onto the ferry, Big M's car and room keys would be heading to the other side of Puget Sound. So we piled into my rented Elantra in hot pursuit, frantically trying to get through on the cell. We were closing on them on the road to the Hood Canal Bridge when we saw a line of stopped cars on the highway up ahead. The geography of Puget Sound means that many routes are dependent on a certain key bridges with no alternate way around, so a stalled line of cars was a bad sign--and we knew that our quarry had already crossed the bridge. We pulled up to the end of the line at mile marker 13, turned off the car, and waited with an inlet of the sound visible through the trees less than half a mile away. We worried that there had been a car wreck, or that a vessel had run into the bridge. Luckily, after about 20 minutes the line started to inch forward and then Big M discovered the cause of the delay. Through the trees he pointed out a pair of dark rectangles moving low on the water--the conning towers, or "sails," of two nuclear submarines. The bridge had been opened for them to pass.

Within minutes we met the other car and retrieved the keys. Then, basking in the glow of our successful showdown with America's undersea strategic nuclear deterrent, we turned back toward Port Townsend. Back at the B&B, Lady M and I shared a quiet moment sitting in comfy chairs on the bluff, watching the sound and the coastline and the mountains fade into the twilight. Later folks in our party went out to the local blues festival, but, having boarded the plane straight after a day and a half on duty and an overnight call, I was too exhausted to go out.

The next morning was quiet and hazy and I hit the road early, waving goodbye to Lady M as the Elantra's taillights disappeared into the marine mist. I was overwhelmed with nostalgia for the Pacific Northwest--the mountains, the water, the tree-lined valleys, the morning mist that burns off into perfect summer afternoons. I crossed two major bridges on the way back, the Hood Canal (low on the water) and the Tacoma Narrows (very high off the water), and each time both the far end of the bridge and the water below were obscured by mist--bridges through the clouds.

Sadly, my flight left while I was still standing in the TSA's half-mile-long security line at the airport, so I didn't get home until quite late last night. Finally descending through the dark towards the Missouri River I considered my baggage claim tag with its printed inscription "Sioux City SUX" (they really need to change that), feeling awfully homesick for Puget Sound. But after spending an eventful day in the hospital and clinic, and treating myself to dinner at the Cow, I'm back in the western Iowa saddle and looking forward to the next two weeks of my sub-internship; rejuvenated, if not actually rested.

Typhoon Usagi

Typhoon Usagi hits southern Japan
Eighteen people were injured and thousands sought shelter as Typhoon Usagi struck Japan's southern island of Kyushu.

Here's a picture of Usagi:



You wouldn't think she could do all that much damage. Of course, she has grown a bit since this picture was taken.

Coming soon: Godzilla vs Usagi!

On-Call Liveblogging

Tonight I'm on call with three services--Family Practice, OB, and Pediatrics--and things are very quiet. Just a minute ago I grabbed some dinner, observing the two cardinal rules of eating while on call:

1) You're allowed to eat anything you want; diets don't count, as long as

2) whatever you eat is portable and easily gobbled, since the probability of your pager going off is proportional to how much you're enjoying your calorie-laden treat (see Rule #1).

My choice tonight? A cheeseburger from the hospital cafeteria. And I got to eat the whole thing. Mmmm....

Noon Conference: Man vs. Beast

A lunch hour tradition at many hospitals is noon conference, when faculty, residents, and others from various disciplines gather for a lecture and lunch (free food being a major draw for the students). Yesterday I was in the E.R. late in the morning stitching up a laceration, so I was late to noon conference.

I walked in, not knowing the day's subject, and saw that the title of the PowerPoint slide up on the screen was "Mechanisms of Injury in Bison Attack." Wow, I thought, am I in the right room? Sure enough, it was a Wilderness Medical Society presentation on wild animal attacks. Much useful information was provided, such as recommendations for antibiotic treatment of alligator bites. You never know when that might come in handy.

Baby's got the bends

I'll be spending this afternoon in OB clinic, so in between patients this morning I'm reading up on the latest guidelines for prenatal care. I see that the American College of Obstetricians and Gynecologists recommends that scuba diving should be avoided during pregnancy because the fetus is at increased risk for decompression sickness. Now I'm stuck with the mental image of nine-months-pregnant women in wet suits exploring coral reefs. There's probably something wrong with me.

A Field Guide to the Medical Team

Many of the posts on this humble blog have to do with my day-to-day experiences, and central to the day-to-day experience of a medical student is the carefully-defined hierarchy of the medical team. So here's a brief guide to who's who in the group of white-coated strangers that wakes you up at 5:30 in the morning when you're in the hospital to ask you if you know what year it is and to please describe your last bowel movement.

The Attending Physician (a.k.a. "Staff," "Attending," "The Doctor") is the boss. At an academic medical center this would be a faculty member. The Attending is ultimately responsible for every patient on the particular service. When someone mentions "the doctor" without a qualifier, this is who they're talking about.

The Senior Resident (a.k.a. "Senior") is a resident physician in the last (or, sometimes, penultimate) year of residency training. Since they are just finishing their training, Seniors are generally extremely knowledgeable about the details of their specialty and the procedures of their particular hospital and floor. They're often the most relaxed and confident member of the team after the Attending, because everything's fresh in their memory and they're almost finished with the gruel-o-thon of medical training. You can usually count on them to have the answer to any question. They are responsible for making sure that the team runs smoothly and can answer any question and perform any task that the Attending requests regarding any patient.

Other Residents (a.k.a. "Mid-Levels," "Junior Residents," just plain "Residents") are between the first and last year of residency training. They are knowledgeable and gaining confidence and are responsible for an enormous amount of the physician care that happens in the hospital.

The Intern (a.k.a. "First-Year") is in the first year of residency training. This year has a tremendously steep learning curve and is considered to be one of the most demanding periods of medical training. Over the course of the year interns progress from being medical students to being in the thick of things. They are expected to know everything a doctor should know, and they're picking it up as they work. Interns start their year on July 1; when you talk to an intern remember that that person has not slept since that date, regardless of what today's date is.

The Medical Student (a.k.a. "Student," "Hey, you," "Get out of my way") is usually in the third or fourth (and final) year of medical school. They desperately try to learn everything they can, run down the halls to keep up with the team, and live under the constant threat of public humiliation. They can be identified by their short white coats. If there are multiple students on a team a strange dynamic can develop based on camaraderie in a trying situation and competition for the grades that are the life's blood of medical school.

Elaborate rules govern the behavior and interaction of members of the team. For example, the most junior member present is traditionally expected to present the patient to the most senior member present. The most senior member present will pose questions (called "pimping") to the most junior members (e.g. "what is the classic triad of signs and symptoms of the patient presenting with normal pressure hydrocephalus?"); if the students can't answer it the interns are expected to, and then the junior residents, and on up the food chain.

A classic and more complete (albeit slightly crude) description can be found here.