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.