Top 3's From Summer Medicine

So after taking a couple weeks off from medicine completely, drinking my weight in beer, and catching up on all my trashy reality television (seriously, its the closest thing to crack you can dig up without having to talk to a large man named Bubba) I've finally started seeing patients again and dusting the cobwebs off the old hippocampus (see left). Medical school has taught me that its awe-inspiring how much you can learn in a couple weeks. Summer break has taught me that you can forget all that information plus tons more in a couple weeks more. But I'm starting to get back into the swing of things. This summer I am doing a preceptorship with a cardiothoracic surgeon (my 13 year old self would have wet himself at this sentence), and picking up a few shifts down at the free clinic. I'll muse on the deeper ruminations of each opportunity later, but for now I'll just present my top 3 experiences from each so far.

THE OR:
|| My First Cabbage ||
The coronary artery bypass graft (or CABG... or "cabbage") is the most common procedure in CT surgery. Layman's terms the "x bypass" surgery. For most CT surgeons, this procedure is as mundane as the morning coffee, but for a medical student seeing the procedure for the first time, it's pretty f'n cool. This one was cool because it was a throwback to my wide-eyed "this is super awesome" pre-med days. It was also cool because it really shows some of the ingenuity employed in surgical techniques. I've known that the internal thoracic artery (or internal mammary artery) is the most common graft harvested for use during the bypass due to the dual-circulatory blood supply to the anterior thoracic wall. But I always assumed you simply cut out a length of the artery necessary for the bypass and suture in one end to the appropriate coronary artery and the other end into the root of the aorta. In actuality, in most cases things are done slightly differently, with the surgeon dissecting the artery away from the sternal wall, ligating it at its distal point, and redirecting only the distal end to the point past the coronary artery stenosis. This allows the natural circulation of the IMA to supply blood to the coronary artery and has the advantage of removing the need to incise into the aorta, which is one of the most post-op complications-wrought steps of a CABG. Small difference technically which has big implications for post-op prognosis.

|| The Bi-Polar Heart ||
Saw an atrial septal defect (ASD) repair, a procedure that is common and straightforward in pediatric cardiac surgery. Most ASDs are found and repaired within the first few years of life. The difference in this case was that the patient was a 71 year old man, who has lived his entire life with a 3cm hole between the atria of his heart and a significant left-to-right shunt of his circulatory system. With so many years living with his condition, his right atrium had dilated to 60cm in circumference (when normal is under 20cm). Yeah, this guy's right atrium was almost as large as the rest of his heart. Besides making for one strange looking heart, the large floppy atrium allowed a big window to look into the heart during the ASD repair so I got a good look to see how the pericardium patch was applied to the atrial septum.

|| The "Holy Crap That's A Big Surgery" Woman ||
This one was a 5 hour surgery on a woman in severe end-stage heart failure. The patient underwent a two-vessel CABG followed by an atrial valve annuloplasty and a tricuspid valve annuloplasty. Layman's terms: a double-bypass heart surgery with two valve reconstructions. Essentially got to see three different surgeries all wrapped into a nice little wrapper. The most important thing I learned from it: I need more comfortable shoes. And never forget coffee is a diuretic.

THE CLINIC:
|| Love The Thyroid ||
Saw a patient with Graves' Disease who had been upping her carbimazole dose (an anti-TSH drug) to try to get her TSH levels back into normal range. She came in complaining of fatigue and irritability, two common symptoms of hypothyroidism, but also common symptoms of many other diseases. If it wasn't for her Grave's Disease I'd have had to idea to think "thyroid" in the diagnosis. This one stuck out to me because I have had a handout on hypothyroidism sitting on my coffee table for the past 8 months that I still have not gotten around to reading. And after a significantly humbling experience pow-wowing with the attending where I practiced my favorite "stoned pufferfish" expression as I had not a single answer to any of her questions, I found the patient had a laundry-list of all the other symptoms associated with hypothyroidism (hot/cold sensitivity, dry patches of skin, weight gain, depression, hair loss, constipation), which would have been readily available to me if I had had my coffee table with me in clinic. Note to self: coffee table fits in back seat of car.

|| I Do Not Speak Hausa ||
Second patient is a diabetic Nigerian who spoke minimal english, and to further compound issues, had significant hearing loss in his left ear. To further compound issues he came in reeking of alcohol, and had admitted to alcoholic habits in the past that would be characterized as addiction. To further compound issues I had a reasonable amount of clinical suspicion he was suffering from severe depression. So I had a drunk, depressed patient with wildly uncontrolled diabetes who I had to talk to through his one good ear while he comprehended maybe every 5th word out of my mouth. A complicated clinical situation in general, but especially difficult when you cannot express the nuances and expansiveness of the english language to the patient. A frustrating situation, because there was a great deal of good we could have done for this patient if not for the lost-in-translation issues. But we made sure he had access to his insulin and was scheduled for a follow-up, so there's always hope for the future.

|| Future Rap Video Girl ||
15 year old girl comes in, leaving mom to wait in the hallway. Had started birth control a month ago in order to control her periods. Stopped after 3 weeks due to nausea. Only, after stopping birth control, the nausea continued. (*red lights and alarms* All hands to battle stations!) One pregnancy test later, I'm talking to a visibly shaking pregnant 15 year old girl. On counseling, found out she has had 12 sexual partners in the past year, and uses a condom "pretty much always." Hot damn, that's a more extensive resume than I have accumulated in the past 22 years of my life. Counsel her on the importance of ALWAYS using a condom, the dangers of the money-shot (ok, maybe not), and sent her on her way clutching a pamphlet with the phone numbers of various teen pregnancy resources in the area. On the way out, the mother comes up to me and talks to me about her daughter's nausea. Asks if her daughter should keep taking her vitamins. I tell her, yes, her daughter should take her multivitamin every day, to follow her weight at home, and to make sure she gets her protein. HEYO! I'm going to hell.

Ok, that's way too much writing for having to be up at 5am tomorrow. Ah, medicine.

Eat two weeds and call me in the morning.

So this arrived through my mail slot as part of a commercial ad packet the other day:
Wow, all these years I thought it was the diabetes, the hypertension, and the cancer that was whacking off our population base. Little did I know it was actually colon gunk. What a waste of a $160,000 degree.

I could spend the next 500 words mocking the above ad, but that's just too easy. But it does offer an opportunity to talk about the supplements industry. I preface this rant by saying that I do not believe "organic" medicine to be completely ineffective, supplements to be completely useless, or that either do not serve a purpose in the medical world.

Herbal supplements irk almost all doctors. The general public loves them. This is a problem. Let me propose a scenario for you. You come in to visit your doctors office complaining of peripheral neuropathy, fatigue, etc. Blood tests reveal you have type II diabetes mellitus, and your doctor prescribes a medicine to get your blood sugar levels under control. Only thing is, when you fill your bottle of pills, every pill has a different dose of drug in it. Some have enough to keep your diabetes under control, others not enough so you feel symptoms again, others too much drug and you plunge into symptoms of hypoglycemia. Every time you pop a pill, you don't know if it will actually help, will harm, or do nothing.

This is the reality of herbal supplements. Herbal supplements work because they have ACTIVE DRUGS in them. It is the ACTIVE DRUGS which are helping you, not the fact that you just ate the pill form of a weed. But the reality is, the supplement industry is wholly and utterly unregulated. The amount of active ingredients within every pill is not checked (and studies have indeed shown levels of active ingredients to vary widely in supplements even within the same bottle of pills). Supplement companies can claim their product is capable of anything, and able to use any number of questionable characters to endorse it (You may see "Dr. Bumbleweed" in big letters on the screen but you miss the TINY asterisk in the lower left corner saying "*PhD in Ceramics"). And people eat it up.

I don't know where this public distrust of conventional medicine but patent obsession with "all natural" products came about. But I do know its incredibly dangerous. Every physician and medical student wishes they can go to town like a 5th grade teacher with a red pen and FDA-like force on the entire supplement industry. But the reason we feel this way isn't because we think supplements are useless. We feel this way because they are dangerous. The active ingredients in supplements are DRUGS. They interact with other DRUGS. Some of these interactions are dangerous and life threatening. Yet people blindly eat up the claims of "natural supplements" and pop these pills with blatant disregard for potential cross-reactions. We are fast approaching a nationwide need for supplement regulation and control.

And for the love of god, there is NOT a pill that can cause you to lose "excess body fat" on just you stomach, thighs, and ass. You lose it everywhere, or nowhere, so go stock up on those vegetables, put down the Big Mac, drink some water, and go for a nice long walk. Yes, with the simple GetYourAssOffTheCouch Regimen you too can watch fat MELT from your body and have unprecedented levels of energy. You'll feel great, look great, and all your friends will notice too! Hi, my name is Dr. MedZag* and I'm here to tell you the GetYourAssOffTheCouch Regimen has impacted thousands of lives as people were saved from their excess weight and low self-esteem. For 3 payments of $39.99 we'll send you the GetYourAssOffTheCouch Regimen Kit, including, a salad bowl, a water bottle, and a fanny pack. But if you order today, we'll throw in this placebo FatBuster pill for free. Call now! Don't miss out!

*Not yet doctor, but will sell soul for money

Tom Hanks will kill you.

An article on CNN.com caught my eye the other day:

Man designing Camry hybrid works self to death

One of the main highlights of the short article is the following blurb:

"The man who died was aged 45 and had been under severe pressure as the lead engineer in developing a hybrid version of Toyota's blockbuster Camry line, said Mikio Mizuno, the lawyer representing his wife. The man's identity is being withheld at the request of his family, who continue to live in Toyota City where the company is based.

In the two months up to his death, the man averaged more than 80 hours of overtime per month, according to Mizuno."

This is not a unique occurrence in Japan. It happens with enough frequency that they actually have a term for it: Karōshi... occupational sudden death from overworking.

Now time for some basic arithmetic. Assuming they are talking about 80 hours of overtime a month in accordance with the Japanese work week (46 hours per week, thank you wikipedia), that means that the unfortunate Toyota employee from the article worked (46/7)*30 + 80 hours a month... ~277 hours.

Now take your average US resident. Under the new work week restrictions, US residents are "limited" to 80 hours per week (though many work more secretly to gain more experience or due to underlying program expectations... SSSSSHHHHHHH). (80/7)*30 hours a month... ~343 hours.

Note this post is in no way meant to belittle the unfortunate tragedy of this man's death. But it does offer a unique insight into the under-the-radar life that people in medicine live. Everyone I talk to outside of medicine understands and sympathizes on some level with the long hours of the field and realizes that a 36 hour shift is not good for the decision making processes. But if a resident were to die from overworking, I don't think it would illicit more than a curious yawn from the general public. Everyone I talk to outside of medicine also expects perfection from their doctors. At first glance these two things, sympathy to mistakes and expectations of perfection, seem utterly incompatible.

Of course the conundrum is that residents do not work so many hours simply as some form of primitive medicinal hazing ritual. Residents work so much because they have to. The Medical Knowledge Ocean is vast, and a single resident but a small speck upon a life raft on it (Wilson sometimes accompanying). Even cutting resident hours down to 80 hours per week, which some professions would be considered ridiculous, we have already seen a greater amount of graduating residents seeking fellowship feeling that they have not had enough training to enter individual practice on their own. With talk of a further reduced 56 hour work week for residents, the debate between the "enough hours to stay sane" vs. "enough hours to not become Dr. Death" debate has gained even further ammunition. The benefits of work hour restriction are obvious. More balanced and well adjusted residents. Less medical mistakes due to sleep deprivation. Candy canes and bubbles and rainbows and shit. The drawbacks are perhaps less obvious but just as important. Necessary longer periods of training on an already exhausting path. Losing the lessons learned from being in the hospital to follow patients from admission all the way through the course of treatment. More time with that "interest" ticker steadily clicking away on student loans.

Personally, since I am firmly plopped on the "baby" end of the medical student age spectrum, the idea of extending residency another 1-2 years in favor of more sane working hours appeals to a certain side of me. After all, whether I am 29 or 31 when I leave residency is apples and apples to me. But the path of medical training is a long and arduous path, and I can certainly sympathize with my older classmates who find the idea of even 12 more months of residency truly gross. And 56 hours doesn't seem like enough time a week to learn what you need to in medicine.

Of course, its easy to spin the wheels in the ol' noggin about this topic when my days still consist of a schedule largely under my own control. It will be interesting to see how my opinions change as I'm thrown into said Medical Knowledge Ocean and told to survive, with the nearest island far enough away it will take 80 hours of paddling a day to reach it in 5 years.

But the idea of residents dropping dead in the hallways, being picked off like flies, in an epidemic of karōshi is a funny image to think of. In a morbid, real kind of way.

"Oh, You Mean Like Grey's Anatomy!"

It's often difficult to understand the culture of medicine unless you are in the middle of it. So when I talk to non-medical friends about my life and times in medical school, they draw upon the best thing they know about what I am going through.

Watching Grey's Anatomy.

Inevitably, if a story I am telling or an experience I am describing even vaguely resembles something from the television show, I get the line that makes all med students cringe: "Oh, you mean like on Grey's!" It makes sense of course. If I talked to a person who was in a traveling circus, most of my ability to relate to their life would come from watching Dumbo as a kid.

Now any med student/intern/resident/attending can tell you medicine is very much NOT like Grey's Anatomy. It's at very least half the boobs and half the libido. Which is why my interest was piqued when ABC showed trailers for their new show "Hopkins," which was billed as the "real life Grey's Anatomy."

You can watch the first episode here. I was understandably skeptical when I cracked a beer and went to watch it, since real medicine makes for horrible TV. It's a lot of boring, mundane, and paperwork, punctuated by rare moments of shit you just can't make up. Overall, I came away pleasantly surprised with the show so far. It's refreshing to see a show that humanizes doctors and the scenarios they crafted were very real. And anything that gives the general public a better view of how ridiculous physicians' lives can be sometimes is definitely a step in the right direction.

Of course, the show is partially, by its own nature, a visual and verbal fellating of the John Hopkins institution, but the Hopkins worship wasn't too bad.

Anyways, it's a 6 part series so we'll see by the end whether the show has degenerated into ER with bad actors, but so far, so good ABC. So far, so good.