This thing I refer to as My Life

They tell you as a medical student that you will know if you should stop an exam.

My senior resident tells me I have a consult in the ED. It's a young man that was brought in the day before for confusion possibly follow smoking marijuana, had a CT and was released after the preliminary read was normal. The final read found a small lesion so he was called back to the ED today. My senior says, "Go figure out what's going on!"

I saved the work I was doing, gathered my notes and headed to the ED. I start circling the ED looking for his bed because he's in a hall bed, not a room. That is usually a bad sign that the ED is filling up.

I introduce myself to this young, *very* fit (read muscular), man and ask him how he is doing?

He furrows his brow, looks over at his mother, nostrils flared, as he runs his hand across the whisper-long hair on his head. I turn to his mother and introduce myself to her and ask her how he has been doing. She starts telling me the story of how he was just a normal young man a couple of days ago. He was happy, chatty, a good kid. I go get a box of tissues as the emotions start to swell.

I pull up a chair and sit next to him. I ask him a few questions. His attention distracted by each passerby, each loud sound behind him. I get no response other than his rubbing his hands over his head. Not absolute, but almost in constant motion. I turn back to the mother to get more of the history, more of the story. There is nothing particularly unusual. He was fine...until he was not.

Ready to work on the physical exam, his mom asks if it is okay to check on her daughter out in the waiting room. She tells her boy that she will be right back; that I am going to examine him; that he should be calm. I ask him to tell me his name...nothing. I ask him to tell me where we are...Are we in a diner?...Are we at the mall?...Are we in the hospital?...He rubs his head and starts grinding his teeth. His breathing is odd, too. Hyperventilating, but not really. Just very deep breaths with large spans of time between. Can you tell me what year it is?

Can I tell you what year it is?!

Yes, it's important to this exam. We want to make sure you're okay.

He squints his eyes...it's 2006.

What season is it?

Spring!

What month is it?

March.

What's the day and date?...he furrows his brow and thinks for a bit. He's not sure.

What town are we in?

Ann Arbor.

What hospital?

Why are you asking me such silly questions? He says in a soft, but distinctly annoyed voice.

It's important so we can know that you're okay.

U of M.

Okay, great! (I said “great” a few times with his other answers, but it doesn't read as well.) I asked him to memorize three things and that I was going to ask about them later: fish, tree and red. He repeats them right away without any problems. I ask if he has got them memorized. He nods.

Can you count backwards from 100 by sevens?

93......(the level of stress on his rises)

How about, can you spell the word, world, backwards?

....d....(again, signs of agitation and irritation as the moments go by)

I hold up my pen, "tell me what this is called?"

It's a pen.

I point to my watch and ask.

It's a watch.

I start to think if I ask him any more of these questions I'm going to be in trouble. So I move on to the next part of the exam. He allows me to test his peripheral vision and perform a fundoscopic exam--which I try to do quickly because it put me in a vulnerable position. I check his pupils; then ask him to follow my finger. His arm folded, he just lies there. He does not look in any direction but straight ahead: grinding his teeth, biceps flexed. I start testing his muscle strength for asymmetry. All symmetric--solid as a brick house. This part of the exam annoys him even more. His mother came back during this part of the exam but it did not seem to calm him. I asked him if it would be okay to test his reflexes. He looks at me in a way that I cannot describe. In a way that I'm getting ready to wrap up this exam. In a way that I'm happy I'm not in an enclosed room. His mom tells him to relax and just lay there and let me test his reflexes. I go to test his bicep reflex and his arm tenses. Both his mother and I ask him to relax. He does, until I touch his arm. Fully contracted--rock hard. I try to test the reflex but get nothing. I tried a few other sites, but nothing. Every time he fully contracts the site I'm trying to test. He keeps sitting up, looking around, huffing, grinding his teeth. It was the point of diminishing returns.

If you pay attention to the patient, you'll know when to stop.

It is visceral. You will know.

Riding on the bus today: now that I am on neurology consults we start “late” enough in the morning so I can. The bus driver pulls into the first stop in the hospital. He swerves a bit into the covered driveway because the driveway he usually takes is block. It’s blocked by a man lying in the road next to his car. His wife and a nurse are by his side. Someone on the bus comments, “I wonder if they need some help.” To which I responded, “He’s about to get a bus-load of help!”

I went over and introduced myself and asked how I could help. The nurse was keeping him still as she explained what happened. He had a folded blanket under his head and one over him but I placed my winter coat on top just to give a little more warmth. She told me that he was a patient here, on chemotherapy, and was here for an appointment. He had just gotten out of the car when his legs buckled, he fell backwards, hit his head on the asphalt and briefly lost consciousness. The nurse barrowed my pen-light to check his pupillary reflexes and I tried to shield his eyes from the morning sun so she might actually get to see a reaction to the flashlight. I asked him for his name, where he was, the date and what happened to him--I am on neurology after all. He gave all correct answers and remarked that he really felt okay. But, he seemed to understand that he needed to keep still. The paramedics had been called--yes, it is odd that if you have problems when you are at a hospital that EMS still has to come in the ambulance. A police officer arrived, placed his coat on top of mine and made sure traffic was blocked. Then a pediatrics-oncology attending arrived, introduced himself, and the nurse and I told him the story. He asked similar question and started doing a physical exam: heart, lungs, wiggling of toes. It would turn out that the patient was actually going to be seeing one of the attending’s coworkers. A person from the ED arrived with a crash-kit followed by a critical-care resident. The resident and attending talked things over for a moment and the ambulance arrived. The EMS team checked his cervical spine and did some muscle strength tests and, at the end, decided to let the fellow go on to his appointment. He had a good sized bump on his head, but really seamed okay: not only to himself but us, too.

Certainly an exiting morning, however it also meant that I would arrive late. I explained what had happened but it sounded like “the dog ate my homework!” Later on that day I was with one of the Neurology residents when the CCU resident walked by and asked me what happened to the gentleman this morning was--I think he had left as EMS arrived. I told him and then said, “Hey, you can vouch for me this morning!”

Below is a post from the official (med school) site. Things are well here and on the warm side. We're planning to have the year's first BBQ with the neighbors today if the rain holds off. I had a great time in surgery, but I'm looking forward to being on some lighter rotations for a while. Can't say there is much personal stuff to say because I really have not had any time for personal stuff! I'm still agonizing over what I should do when I'm done and I really need to decide by mid summer. Time is ticking!

I’m not sure if I mentioned this before, but I, oddly, got along better with the surgery residents and attendings (most of them) better than any other rotation. What is funny is that I have had several people (including other attendings) warn me that my personality was going to get me into serious trouble in surgery. Maybe it was just the group of people with which I was working, but I had a substantially better time than most of my peers. (I got lucky, for once.)

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How pathetic is this? It’s Saturday morning, I had the whole night to sleep but I got up at 04:45 and could not fall back asleep! Sad! And I blame it all on the last two months and one week of surgeons! How dare you disturb my ability to sleep the day away! Oh well, at least I have time to post.

As usual, things get busy as shelf exams get closer which is why there has been a paucity of posts over the last several weeks. The surgery shelf and oral exams were actually at the beginning of this month after which I switched to neurology with my first week being pediatric neurosurgery. Whereas neurology is not supposed to be extremely busy, especially because I’m on consults, neurosurgery is as busy and any other surgery rotation.

My last post was the week before our finals and it was my turn to go on a procurement. This is quite a surrealistic experience but a positive one none the less. Tuesday afternoon I caught word from the interns that there would be a procurement later that day. At first I was excited about the possibility of flying in the helicopter or the jet but I soon found it was to take place at Mott, our children’s hospital. Not to be too crestfallen, but every student on the transplant service hopes to get to take the Lifeflight helicopter as sort of a justification for the abuse that used to take place on the service. (It had a reputation for be very student unfriendly, but that was not the case for us.)

A little while later my pager delivered a message informing me of the event and the time it would take place that afternoon. I made my way to the Mott OR 9; entered the room to find three staff working to get the room ready. I introduced myself and met a really nice RN (I think he is an RN). As it would turn out, I would spend last week (peds neurosurg) in his OR, too, and it was really nice to have a friendly face. It would also turn out that I was very early. Once all of the setup was done, we listened to music and got on the subject of South Park. I showed him how I can play South ParkSouth Park for a little while. episodes on my PDA which led to us watching

Aside: Apparently, enough of the students find the PDA of such little value that the school is considering not giving them out to the rising M3’s anymore. That’s too bad because I think they are great! Not only does it have ePocrates (which is about to expire and be of no value) but also a Nintendo emulator, an Apple II emulator (just so I can say I have an Apple II emulator: not that many of my classmates even know what an Apple II is), I can watch full length movies (which rocks on airplane flights), there is a program that dynamically displays the stars base on my longitude and latitude, an OB wheel, AIM (which the school has locked out), and Quake! This all in addition to the regular stuff like web-surfing, e-mailing and paging: I think the ability to page is the most useful official feature.

I knew the donor was going to be young because we were in Mott. The word was he was a young man involved in an auto accident several days before and just did not recover. The phone rang…he was on the way…final preparations in the room were made. The door opened to a stretcher carrying a very young man being kept alive by a lot of equipment (an ECMO and a ventilator at least). He had better skin color than most of the other people I have seen on ECMO, but he was still. Peaceful. I was sitting in the corner, staying out of the way and the chart was placed on the table in front of me. I started to read through the notes so I could gain an understanding of what happened. It was a MVC (motor vehicle crash) rollover and at first they thought he was unrestrained but later notes would remark that he was belted. When he first arrived at the hospital it sounded like he was doing okay. As I flipped the pages the downward spiral of a traumatic brain injury was readily evident: the shift from localizing to a sight of painful stimulation like pinching a shoulder or rubbing the sternum to generalized withdrawing, to flexing, to extending, and finally not responding. Over the course of just a few days his brain was dieing but his body was too young to quit. It was sad. It was unmistakable. At some point his parents agreed to the selfless act of allowing there son to be an organ donor. There is a special group of people at the U that are specially trained to help families through this decision making process. I cannot even image how to broach the subject. I am not even sure I want to know. I do know that I hope I never have to make that kind of decision.

The surgery starts pretty much as any surgery does. The windows are larger than one is used to seeing which makes it a good anatomy experience. One difference is the visceral sensation when the organs come out without anything going back in to replace them. Oddly the donor nephrectomy is not the same sensation.

The liver, kidneys and pancreas are out: the ECMO is off. The fellow instructed me to help the attending prepare the liver for transplant on the “back table” while the he closed. I had hoped to get to spend some time going over the anatomy but things were tense enough. The back table is a sterile draped table with a handful of instruments and a single overhead light. I sat opposite to the attending and we started to dissect out all of the vasculature from the connective tissues. I provided tension on the tissue while the attending cut and, for once, I was able (allowed) to maneuver myself instinctively and this garnered a lot of praise from the attending, which was really nice. The quotable was, “You’re hired!” We worked for around an hour, it seemed. I really lost track of time so there is no telling how long we were actually working at it. When the fellow was done closing the donor he offered to take over for me. Much to my surprise the attending said, “No, that’s okay. We got it.” (There was an odd dynamic between me and the fellow. He was on vacation for the first part of the service and when he joined us he never really assessed my skill level and I never really got to do much when he was around, so I think he just assumed I was all thumbs. I think he got along much better with the other two students.)

We triple-bagged the liver, packed it in an Igloo ice chest and off it went to the U. I took a look at the “keep the kidneys-alive-machine” which continuously pumps this fluid through them as they sit elevated in a glass box above the machine. It was much more weird looking than I can describe.

We moved the donor back onto the stretcher and the white body-bag zipped.

I walked over to the U to find out where things were with recipient procedure. The team was still working on extracting the recipient’s liver and one of the other attendings was at the back table doing more prep work. In the other procedures, there is always prep work at the back table before the implant but I did not know that it happened twice. I scrubbed and helped again. I found out that my hands were really fatigued because, unlike when I was helping at the donor site, this time I would occasionally--accidentally--release the tissue from my forceps. My fingers were fatiguing: burning. We spent another hour or so further dissecting the liver.

By 03:00 the next morning, the transplant was done. It went smoothly--as smoothly as a liver transplant can be. We returned to the 5th floor of the main hospital, went to our respective call rooms and slept for a few hours until morning rounds.

Oops! I ended up in Neurosurgery for my first week so time is still a little tight. Hopefully I'll get back to posting soon. If not this week, I'll be more 8-5 starting next week. Stay tuned!

Finished up my Surgery shelf and oral exam on Friday. Slept most of Saturday. I'm working on a big-'ol-nasty blog posting which will holpefully be up later today (since it's now Sunday). We're still alive and doing pretty well. More to come..