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Tue, Sep. 9th, 2008, 07:40 am

My final weeks in surgery were spent on urology.  It takes a special kind of person to do urology.  They tend to have a good sense of humor and be quite outgoing.  Some of them have to learn a little tact in discussing these problems with people.  For me, it was way too many genitals for one week. 

The urology department at my university is currently ahving a slow time.  One attending quit, one got demoted, and the third is simply overworked.  But at least he is really good.  He interacts with the students and the residents constantlyy, promoting a great learning environment and allowing for interaction.  Unfortunately, one attending is not enough to keep a good program going, so tehre was still a shortage of cases.

Urethral repair: 1 (This was awesome.)
Cystoscopy: 5
Transcutaneous nephrostomy: 2
Removal of tubes: Lots.  (They put a lot of tubes up there.)

Overall, urology is not for me.  The people were great.  The work was itneresting, but it didn't get me excited.

Two more notes, one good and one bad.  First the bad.  The second student on my team was a slacker.  I would go to procedures and follow the residents on the floor to help and to get the opportunities to learn.  he would sneak off to find time to study.  This is good for me, and bad for him.  Since this is the second section I have worked with him, it was exactly what I had expected.  However, by the end he was starting to think that I was trying to make him look bad.  I thought he was doing a perfectly fine job of this on his own.  He asked me to skip a surgery so he would have a chance to be there on his own.  I still think he is a jerk, but so does everyone else who has worked with him.

On a good note, during the surgery I skipped for him, I was trying to finalize plans for travelling to my grandfather's funeral.  When I informed the residents that I would be leaving for a couple of days, they told me not to worry about trying to make up the time or coming in for the next couple fo days at all.  They were great to work with. 

Surgery summary: Nothing really caught my eye.  If I do end up in surgery, it will probably be adult otolaryngology (ENT).  But I will be looking elsewhere for my career.

Tue, Aug. 19th, 2008, 11:26 am
Adventures at the VA.

There are a couple of veteran's administration hospitals in St. Louis which are trying to get a couple of things under control, namely morbidity and mortality.  This is where I went for my two weeks of general surgery.  The VA is known for certain aspects taht are unique from other American hospitals but have been rumored in socialized medicine.  These include lack of attention to detail, poor information management, and failure of staff to complete orders.  The combination of tehse factors leads to the residents and students having to either do everything or follow up constantly on the teams that are consulted.  We spent a lot of time doing all of these things.

General surgery is generally associated with the abdomen, which means hernias and bowel obstruction.  Since there is not an independent vascular team at the VA, we also did the vascular surgery.  One of the nice things about the VA is how involved the students are.  Students are allowed to do many things that they are not allowed to do at the university, including some of the suturing and cutting, changing bandages, replacing chest tubes, and about anything else, short of performing the surgery, that the student asks to do.  This leads to a great opportunity for the students to learn.

However, all the surgeries we performed were limited in scope.  Any patient who is high risk is sent out on a fee-basis to one of the two medical schools in town to decrease morbity and mortality at the VA proper.  This is an administrative way of fixing intrinsic problems.  The high mortality could be due to a combination of factors, including letting students do too much, not having sufficient followup from staff, and having old veterans who don't present for medical care until it is too late to do antyhing.

Hernia reductions:  3 - midline, bilateral inguinal, and inguinal.
Laparoscopic cholecystectomy: 1
AV fistula repair: 1
Peritoneal catheter placement: 1
Sebaceous cyst removal: 1
Lower limb arteriogram: 1

Tubes placed: 1
Tubes removed: 5

Overall, I loved teh residents and attendings at the VA.  They were very willing to engage the students and teach.  One of the residents would provide pertinent questions for the students to research, and then he would follow up the next day with the attending present to provide corrections.  From a teaching standpoint, this was teh most well run team I have been on.  They did an excellent job of involving students and making them think through the processes.

While I loved the people, I hated teh subject.  I decided that general surgery was not for me when i saw the first failed colostomy bag (an external drain for stool).  Since there is a lot of work on the bowel, the floor frequently smell of stool.  If they cleaned more often or more effecetively, this would not be a problem.  However, in a government run and funded hospital, there is some lack of cleanliness.  The wards always smelled, and there was little that could be done.  

But I made it through the two weeks.  I learned a lot.  Now I get to move on to urology.

Wed, Aug. 13th, 2008, 05:15 pm

Ear Nose and Throat doctors are often referred to as the "pretty boys" of surgery.  The surgeons would respond by saying they are the ones who are smart enough to choose a surgical specialty that allows them to have time off and is relatively interesting.

I spent half of my time in ENT on pedeatrics and half on adult medicine.  I will go through them separately since they are very different.

Pediatric procedures:
Ear tubes: lots
Tonsil/adenoidectomies: lots
Cochlear implants: 2 (one adult)
Laryngeal polyp removal: 2

That is not a lot of variety.  Pediatric ootolarygology was fairly boring.  We worked with kids with obstructive sleep apnea, hearing loss, or other congenital or peripartum acquired abnormalities.  While the physicians were great to work with, I learned that I do not enjoy working with sick kids, and pediatrics is likely to be very boring.

Adult procedures:
Mandible repair: 2
Parotidectomy: 1
Thyroidectomy: 1

While that may seem like a short list, the shortest surgery took three hours.  Adult ENT was much more interesting.  Much of adult ENT deals with cancer, mostly secondary to smoking.  We counciled a lot of people to stop smoking.  (Lesson 1: Don't smoke.)  ENTs also deal with a lot of facial trauma including people who get smahed in fights or motor vehicle accidents.  These are interesting, but I liked the cancer surgeries better.  I did not find the hearing portion of ENT to be very interesting.  

Lesson 2: If you try to commit suicide, do everyone a favor and DON'T MISS.  When someone puts a gun in their mouth or under their jaw and shoots, they better hit the brain.  We had two failed attempts in two weeks, resulting in one man who will not be able to eat anything more appetizing than a milk shake for the next three months.  At that point, the metastatic cancer will kill him.  In the meantime, he now has to deal with the severe trauma he caused himself, and his family has to deal with his misery as well.  The other failed suicide attempt lost an eye.  Neither are likely to be much happier anytime soon.

Summary: Adult ENT is much more interesting than pediatrics, but it still did not grab me. 

Mon, Jul. 21st, 2008, 04:26 pm

I have survived the first two weeks of the third year of medical school.  Over the next year, I will be writing about the experiences that I ahve had and how much I enjoy the various rotations that I am on mostly for a couple of reasons.  First, I will eventually ahve to decide what I want to do when I grow up, so I have to know what I enjoy.  Recording these reactions will give me a way to remember the clerkships and specialties taht I ahve worked in.  Second, there are some pretty interesting things that happen.  Third, I have to provide a review for each clerkship, and this will provide me a way to remember the things taht happened during the early portions of each clerkship.

The first two weeks was spent on Vascular Surgery.   

Venograms:  multiple
Angiograms:  2
Femoral-popliteal bypass: 2
Below the knee amputation: 1
Carotid stent:  1
L5-S1 fusion: 1 (Multidisciplinary surgery with ortho-spine)

This specialty provided a variety of procedures, including the almost bloodless venograms to the barbaric amputations.  For example, a fem-pop bypass takes almost five hours to complete.  It is elegant and smooth.  On the other hand, amputations involve surgeons pulling out large knives and breaking bones.  These are less bloody than they used to be, but they are still very brutal.

Overall, vascular surgery was interesting.  There is a lot of radiation exposure since the venograms and arteriograms all require perioperative x-rays frequently to determine the patency of vessels at various parts of the body.  However, these are also extremely interesting procedures.

In this rotation, I was reminded that I have forgotten a lot about medicine in the last few years.  It will take some time to catch back up.  I also was reminded taht there are a lot of jerks in the world.  Jerks who give presentations on professionalism and suppressing your inner jerk.  Ain't hypocrisy grand.  A lot of people laughed when they heard this particular surgeon gave this lecture.

Overall, not my cup of tea.  The service was slow while I was on it, so they did not ahve a lot of things to do.  Also, I am just getting used to sitting and waiting for attending physicians.  This involves either looking like a fool while trying to study books in the hall or simply not doing anything in the hall and looking like a fool that is simply hanging around.  

I am sure life will get better, but I did not enjoy this service.  The fellow I worked with was great, but I still left with a sour taste.  hopefully things will get better, but we will ahve to see.

Next up:  Otolaryngology (Ear-nose-and-throat).
Preferred long-term goal: Radiation oncology.

Thu, Jun. 12th, 2008, 12:19 pm
What to do?

Over the last few weeks, I have been busy with a number of things. 

First, our car died, so we went and bought a new one.  We managed to find a Kia Spectra (02) that we liked that was also relatively cheap ($2400).  Since this will primarily be used to drive to work and back, this car works great.

Next, I worked in the clinic on the geritarics team for a couple of weeks to become reaquainted with how to interact with actual patients.  I have been working with serum samples without actually seeing any patients for so long, I thought a brief refresher would be nice before restarting the third year medical school cirriculum.  

This last week, I wrapped things up in the lab, including trying to finalize a paper, finishing any training for those who are staying, and answering a lot of questions taht people would have figured out without me.  Needless to say, the last week has mostly served to annoy me because of the vollume of bad questions that I ahve had to answer.  Thus, I am leaving a day earlier than I originally planned.

Now I ahve to figure out what to do for the next three weeks before my surgery rotation starts.  I am heading to Nebraska for a couple of days to see our friends/distant relatives before they move to Idaho.  Our family is also coming out for a weekend.  But I will still be left with a lot of time to fill.  If anyone has good suggestions, pass them along.  Vacation only lasts for a few weeks, and I have to make the most of it!

Mon, May. 19th, 2008, 03:31 pm
Cleaning out space.

This week, I am cleaning out my space at work.  This has become an exercise primarily in throwing out old papers.  Over the last four years, I have accumulated about 15 years worth of papers on hepatitis C virus, and now I will not be using them.  Also, I have to trim down my lab books to only the bare minimum, which will be easy since I only ever kept the minimum to begin with.  

I got started on this project six months ago when our lab moved to a new building.  However, I still had to keep a number of the papers since I was using them as references in writing my thesis.  Now that the thesis is turned in (including final revisions and technical edits), I no longer need these old papers. They quickly went in the recycling bin.  

While cleaning out my space I have run into a problem: I am starting to feel empty without my workspace.  

I have been surprised to find out how attached I am to the lab.  I am excited to start working in the clinics next week, but I am also feeling quite displaced with my stuff disappearing.  Four years is not a long time to be working in one place, and I knew this day would be coming.  Graduate school was always designed as a stepping stone, in my case back to medicine.  I have been excited to return to medicine from research, so I was not anticipating the attachment that has evidently built up over the years.  

That being said, once I get started in medical school again I do not anticipate being so attached to the old stomping grounds.

Fri, May. 9th, 2008, 09:42 am
I have a PhD, but that does not make me a good parent.

About two weeks ago, we were informed that the Dread Pirate's science fair project had been selected for the city/regional science fair.  Unfortunately, they were supposed to set up the presentation on May 5th.  Since I was defending my thesis that day, we were going to be a little busy.  Luckily, another parent said they would set up the project for us.  

Judging and presentations for the fair were Wednesday night, shortly after our family left town.  Unfortunately, we had other things on our mind, and we completely forgot about the science fair project.  However, Kx was lucky enough to volunteer at school yesterday for teacher appreciation day.  She was present in the classroom when the science teacher for the school presented the Dread Pirate with his second place ribbon.  Evidently, he was very excited.  Until his teacher asked him how the presentation went.  We know he has matured emotionally because he did not start crying.  He had tears, but no sobbing.  We felt terrible.

Last night, we had a little party to celebrate the success of our second grader who did an excellent job on his science fair.  While we helped him organize and finalize things, we made sure that he did most of the work, including typing the segments of his presentation into the computer.  He did a great job.

Congratulations Dread Pirate!

Fri, May. 9th, 2008, 09:26 am
Someone thinks I'm smart. Or at least not dum.

I meant to post yesterday, but it got delayed because of sheer laziness.  

On Monday, I presented my oral defense for my dissertation.  In short, I passed.

Now the longer story.

Over the last month, I have worked very hard in preparing to summarize the work I did over the last four years in a talk of one hour.  This is very difficult, as this work includes what will end up being four scientific publications, two of which are primarily my work.  At first, we limited the talk to the two that were primarily my work with a brief summary of a third.  But we continually ran into time problems.  The talk continued to be close to 90 minutes rather than sixty.  We decided to remove an entire section.  It is still included int he thesis; just not in the oral defense.  We now had a set of data that could be presented in one hour.

The second problem was making the speech comprehensible to people without a background in both statistics and viral genetics.  Aside from my wife, father, and sister, many of the scientist in the room were not entirely comfortable with the statistics we are using to describe differences in viral variability and evolution.  I decided to use a pictoral representation of the diversity of our groups, highlighting the facets that were being compared.  This seemed to work really well, and I got positive  comments about it later.

The defense was scheduled to last about an hour, with a followup ten to fifteen minute question period for the audience.  This would then be followed by a committee meeting including a second questioning period.  What I did not expect was the thirty minute public questioning period.  Most of the questions were insightful and probed specific aspects of the project to clarify related issues, including moving the work to a pre-therapy test for determining response to therapy based on viral genetic factors.  After the extended public questioning, my committee decided that no further questioning was necessary, and they briefly met simply to sign the ballots.  

That is how I got my PhD.  What is not described is the long agonizing over the last month despite knowing that they were not likely to fail me.  I stress about little things, but that is one way that I remain competitive.  My family came out a couple of days early, so they helped me relax.  They also stayed for a couple of extra days to help me wind down and celebrate.  The big party was Monday night: our fourth annual Cinco de Mayo party.  Seventy eight people attended, and everyone said they had a great time.  

Now I am back in the lab trying to tie up loose ends before returning to medical school in a couple of weeks.

Fri, Mar. 14th, 2008, 04:42 pm
Get on the potty train!

I think this confused the little guy for a while.  When we mentioned potty training, he would start looking for a locomotive.  At one point he even chimed in with a "choo choo."  But he has now gotten over that.

Now he wears the train.  His favorite underwear now have Thomas on the back, with a big smile and everything.  He loves them.  They have even beaten out the Spiderman set that he got first.  

We got him interested when we mentioned that big boys wear underwear.  He always wants to be big.  His two favorite people, at times, are his older brother and sister.  He always wants to do what they do, and that means he has to be big.  After six months of encouraging him to try to use the toilet, we finally found something that worked.  AFter he caught the bug, he was free from diapers in less than a week.  

But yesterday was the firsts accident free day.  It happened on our anniversary, which was nice.  He made it all night and all day without getting Thomas dirty, and he was so proud of himself.  

Now we just have to keep it going.

Fri, Mar. 7th, 2008, 01:03 pm
The joys of new equipment.

About two weeks ago we were able to buy a slightly used elliptical from a friend that is moving to Pittsburgh. They sold it to us for two reasons. First, they don't want to move it.  Second, they won't have room for it in their new place.  As a result, we got a shiny almost new elliptical for our basement to go along with our recumbent bike.

The first day I tried it out, it wasn't pretty.  Remember that I exercise four to six times a week on our bike for 15-40 minutes. Unfortunately, elliptical motions are much more similar to running than stationary bikes.  They require many more muscles and you can get a much more intense workout in much less time.  On day one, a managed fifteen minutes, and I paid for it over the next few days.  I was sore in many places that have not been worked out in a long time.  I was walking around like a muscle-bound jock.  Fine, walking in this sense is a general term.  A penguin-like waddle is probably closer to the truth.  

Do I let that deter me?  No!  I go back a couple of days later for twenty minutes.  Twenty-five the next day.  Thirty the day after that.  I now have the time down, but my speed on these workouts is quite low.  I am just glad to get the time back up to where I wanted it.

In the last week, I have been working on the speed.  I decided that I want to go three miles as fast as I can.  As of this morning, that is now under fifteen minutes.  I follow this up by moving to the bike for fifteen minutes.  A half hour workout: half bike and half elliptical.  This has worked really well in keeping my knee in good condition along with giving me a good workout.

I have really enjoyed the elliptical.  It simulates running a lot better than any of the other low impact activities I have tried.  I have wanted one for a while, but it was not in the budget.  We lucked into this one, and we will have to decide what we want to do with it in a couple of years when we move. 

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