SurgeXperiences No. 20

In honor of Dr. Sid Schwab’s masterful edition of the surgery blog carnival, SurgeXperiences, I offer this humble introduction:

Dr. Schwab shows a natural attraction
To verse in utmost compaction.
 He’s written a book
 So go take a look
At our Limerick Laureate in action!

This is the first time I participate, so I’m especially honored to be included in such a creative edition!

My kind of American hero

50 years ago this month, a lanky 23-year-old young man from the small town of Kilgore, Texas went on Soviet soil and conquered an entire nation–truly winning their hearts and minds–at the height of the Cold War, a mere six months after the Soviets launched Sputnik I to start the space race–not with military might, but with music. I am, of course, speaking of Van Cliburn, one of the most famous pianists this century.

Story short, the Soviets decided they were to host a grand competition for the world’s finest pianists, violinists and cellists, all in honor of the famous Russian composer Tchaikovsky. Premier Khrushchev was certain that the Soviets would illuminate the musical world as Soviet musicians would compete and emerge victorious on an open stage for the world to see. I’m sure the Soviet Ministry of Culture had their “hand picked” winner, but the crowds were chanting Cliburn’s name. He was the obvious choice among the jury, and the shock wave was enormous. The soft-spoken Cliburn literally had women screaming as if it were a rock concert, yet Cliburn’s stage presence then and now has always been one of austere sincerity.

So powerful was the “note heard ’round the world,” that the jury had to ask Khrushchev personally to approve naming Cliburn the competition winner. And lets examine some of the luminaries on that jury: Emil Gilels, jury chairman (photo w/Cliburn), Dmitri Shostakovich, Sviatoslav Richter, to name a few: to have won over these geniuses, regardless of nationality or politics, was a feat unto itself. Imagine it! The gold medal of the inaugural Soviet competition in honor of the grandfather of Russian classical music–going to a practically unknown American at a time when the USSR was spilling over with national communist pride. So powerful was this weaponless and honest victory, that Cliburn received a ticker-tape parade in New York upon his return. Usually reserved for sports champions, military heroes, or pop-culture icons, no other classical artist before or since has ever received that honor. Cliburn’s live recording of the Tchaikovsky First Piano Concerto made upon returning back to the USA (with the Soviet conductor and orchestra from the competition no less) was the first classical album to go platinum, selling over a million copies. A classical album!!

No longer making recordings but still playing limited engagements, he is more known now for the international piano competition that bears his name. It shows his character that Cliburn stayed true to his roots and had the competition held in Fort Worth (ie, not neighboring Dallas or any other “big” city) where this small, humble city becomes the musical capital of the world for two weeks every four years. The Cliburn Foundation also hosts a competition for amateur pianists on off-years, something I have always had on my “Have to do before I die” list–just to participate.

Below is a video clip of Cliburn playing the last movement of Tchaikovsky’s Concerto No. 1 in 1962 during one of Cliburn’s numerous tours of the Soviet Union. This one happens to be in Moscow, with the same conductor and orchestra, and in the same hall as when he won the competition four years earlier. You can even see Khrushchev himself applauding during the last few seconds of the video. Understand that this was the same year as when the world was on the brink of nuclear holocaust from the Cuban missile crisis, yet there Cliburn was on Russian soil, wowing Soviet audiences with their own national composers. Seeing the video, it’s not hard to understand how Cliburn was and is a true musical ambassador of peace in the name of great music and art. Enjoy!

(For more, go to the Van Cliburn Foundation page and follow “50th Anniversary” links for more videos and interviews of Van Cliburn then and now)

Grand Rounds 4:31

Blog buddy Dr. Val is hosting this week at her blog, Dr. Val and the Voice of Reason. Go check out the best of the medical blogosphere from this last week.

I will be back shortly.

Hospitalia: The Beginning

So, as promised, here is how all my medical melodrama began. I warn in advance this will be long and in several parts, but I do think it makes for interesting reading. I’ve tried to really highlight the whole “medical-person-as-patient” experience because while I’ve had this or that done or tested since starting medical school, this was definitely the first “real” full-on patient experience I’ve had, and I was surprised how different (at times surreal) the whole thing could be sometimes. Anyway, here’s how it went down…

I was sitting on the floor in a bedroom at my father-in-law’s, organizing items from a whirlwind of internal spring-cleaning and moving, fresh from having orchestrated our stuff here from Mexico. It had been decided that “home base” for Claudia and daughter would be my FIL’s, and we were doing the necessary work to get that done. I had gotten up and took a few steps when I found the ground slowly giving way, my rib cage and left shoulder becoming one with a chest of drawers (believe me, the furniture got the raw end of the deal) — I felt no pain, just blackness…

…until I heard Claudia yelling my name over and over. I had no idea how long I was out, but it probably wasn’t more than a minute or three. Funnily enough, Claudia didn’t even hear a thud; she just happened to walk in and freaked out (naturally) seeing me on the floor. In spite of the grogginess not having worn completely off, I was strangely confident that I knew what happened and why.

Syncope is not something to treat lightly because it is not uncommonly an indicator of grave problems. In the case of the heart, an arrhythmia or some other cardiac problem means not enough blood gets to the brain (excuse me while I kiss the floor). Neurologically, any number of seizure types can be at play here, as well as other neuro stuff I’d never pretend to understand, but it’s not a good thing, and thank God that’s not I was dealing with. No, it just so happens that a week earlier, I had some bloodwork done and found that my hemoglobin was at an all-time low of 7.6. For the first time, my MCV (cell size) had dropped into the 50s. For the medical types, this clearly indicates a chronic anemia, but what was alarming was how fast the Hgb/Hct had dropped. I had an EGD in Mexico just 4 months prior and my Hgb was 10.2 — what gives? Because of these results, I had some more tests ordered, but they were still out; I also had an appointment to see a hematologist because of several oddities I’ve made mention of here before, but that appointment was 3 weeks away.

I did wind up in the ER that evening and was admitted that same night (good thing it wasn’t the weekend or a Monday!) My presenting Hgb was 7.4 and my ferritin, ran later, was 4. Yes, FOUR. Over the next 24 hours, I had 3 units of packed RBCs put in and another EGD, just to be sure. Of course, the EGD came back negative as before, which means that even it’s time for the other scope. Yes. That one.

But before we go there, here are some random fluffs from the first 36 hours or so:

• Because this was clearly a bleed from somewhere (other hematologic oddities aside), it was determined that I needed a digital rectal test to see if I was bleeding down there. I reiterated that guiac, etc. tests have always been negative and that I had no other lower GI signs, but I wasn’t getting out of this one. I had a great ER nurse, and she said that it was just par for the course. But was it the nurse who did this? Oh no, it was Bruiser Brody, bald-headed, goateed cage match wrestler. To add insult to injury, as he put on gloves, I saw he had tats on his potato fingers. “You’ll feel some pressure,” he said…yeah, at about T11-T12. Jesus Mary and Joseph…I could have predicted the outcome of that exam right then and there. I told my nurse, the one with lithe fingers and small hands, that he didn’t even take me out to dinner first. Fully expecting that to be the 100th time they’ve heard it, I found out later it was the laugh of the night for them. Who knew?
• When blood arrives, apparently everyone goes into military drill mode. I don’t know if it was blood bank person or the charge nurse, but there was this exchange of patient, blood type, serial number, and other relevant data exchanged to my nurse like a challenge-response nuclear drill. “Serial X73413, do you concur?” “Yes, I concur.” I was waiting for them to load the IV pump and turn the keys at the same time to start the drip.
• By the time I made it on the floor it was midnight. I was NPO from the time I was taken back from the ER waiting room, and I was dying for something to drink, perhaps even a sandwich or something light. “NPO for your EGD tomorrow.” Dammit! “Look I just got here and I know it’s just after midnight, but come on–can’t I get sandwich or some soup/crackers–something!?” After checking with the doctor, I was allowed to have clear liquids until 1:00am. Bastards. Then he walks his happy ass in there and takes what Jello I did have away because it was red. WTF? This is an EGD for Christ’s sake, do you expect Jello to still be there 8 hours from now?!?! I was pissed.
• I reported the anesthesiologist who did my EGD because he was upset over some scheduling problems and kept slamming things around. I asked what he’d be using for sedation out of curiosity, and he looks at me over his glasses with this scornful look of, “I could make up a word and you wouldn’t know any better,” but he wound up saying simply, “Propofol.” “Oh, OK, thanks,” I replied, to which he just chuckled, fully expecting me to have no idea what he said. But when the cursing and slamming of things started, that’s when I got pissed and said, “Do we have a problem? Because I’m not comfortable with your managing my case if you can’t even manage whatever it is that’s wrong here.” Completely flabbergasted, he just said, “No, that’s fine,” (mind you, no admission here, just telling me it’s fine) and proceeded to explain how the nurses royally screwed things up, like that was going to make it OK with me. I don’t give a rat’s ass who pissed in his Cheerios or how–his behavior was out of line and was making everyone in the room–including me–uncomfortable. There’s more to this story, but it’s not worth going into any more. I had three more visits to the GI lab, but thankfully that was the last time I saw him. (the sedation went fine, thankfully)
• The GI lab was FREEZING. There’s no need for this. Radiology has six-figure CT scanners, million+ dollar MRI machines, and whatever environment those babies need, they get. They’re pampered, lubed, polished, the GE or Siemens guys coming by to do maintenance just because. Some laptop cart with a fiberoptic snake on it doesn’t need a near-zero environment. You have my asshole GI doc (more on that later) who wants it cold, and the tech whose hand is practically shaking as she’s putting leads on me.
• There is a DEFINITE difference between the day nursing staff and night staff. It’s the A team and the C team. When 7pm rolled around, I dreaded what wicked this way would come. Why a night nurse can’t answer the fucking call button at whatever hour at night when nothing’s going on (and I mean this happened many times, so it wasn’t like that one time another patient was nose-diving) and the day nursing staff was on it almost without exception within a minute? I’d walk a ways down the hall and almost every one of the staff were either gossiping or surfing. One of them was nice and predictably would be surfing on a terminal just outside my door, but he wasn’t my nurse. He always got me whatever little thing I wanted, so I appreciated that and made good with what I had. Whatever works.
• Neurology came by for a consult the morning of my EGD. Neuro doc said he was there because heme doc asked. (my mind can see, “R/O neuro origin” in chart…) Fine. I ask his questions, recognize the mini mental status exam as it was being asked, then he asked me to put my hands in front of me and close my eyes. He did a Romberg with me lying down, how lame is that?! He said he didn’t feel it was neuro in origin, hope things go well for me. Deed done, I think, he got to wet his beak at my trough, happy travels. But no–later that day, someone shows up to take me to do an EEG. Huh?! I asked who ordered it, and it was neuro guy..after saying to me point blank he didn’t think it was neuro in origin. It was a disgusting example of milking it, and I refused unconditionally. For all Happy Hospitalist and others go on ad nauseam about consumers wanting everything for free, providers do their nice bit of raping and pillaging themselves. Dr. Supine Romberg had the audacity to come by the next day and asked why I refused the EEG. That bastard I’m sure billed a patient encounter to come to my room to ask why I challenged his judgment, because he didn’t offer anything else. But it STILL doesn’t end there–two days later, a dietician came by because Neuro Guy ordered it, feeling I needed “weight counseling.” While already on the GI service. What an ass.

Tune in for the next installment in a day or two!

The Natural Orifice Consortium

Or more completely, the Natural Orifice Consortium for Assessment and Research, a group dedicated to investigating and exploring ways to perform surgery through natural orifices, such as the vagina, anus/rectum, and about any other opening nature provides:

Using patients’ natural openings (the mouth, vagina or rectum) as entry points to the body is perhaps the intuitive next step to laparoscopic surgery…

The group’s official acronym is NOSCAR–yes, that there is a gratuitous “S” to make the clever “no scar.” When I read the word “Consortium,” I can’t help but think of some underground, covert organization–guys in dark suits, meeting in secret places, speaking in the language of riddles and subterfuge. About orifices, of course, because you can’t talk about that stuff in the open, it’s gotta be in secret. Can you imagine the higher-ups of this “Consortium” going out for a dinner, paying with some black Amex where the business name is embossed on the card? Maybe there’s even a sphincter watermark that needs to be checked for authenticity… OK, I’m blaming my Lortab this late at night, I apologize…back to the real story at hand. (The truth is out there…)

If we were talking a huge fish-gutting midline incision, perhaps going through one of someone’s tender bits and saving days and days in the hospital and weeks of recovery would be a tradeoff. But the article above (which is from Time BTW–there might be something more scholarly out there, but alas, I don’t have those resources anymore) is talking about a simple appendectomy. An appefrickindectomy!!! Why am I shocked? Because even when comparing “open” vs. laparascopic, we’re talking a 2″ or so incision in the RLQ via the external oblique muscle (surgeons, please correct my newbie knowledge here) or a couple of similar/smaller incisions for the lap technique. How on God’s green earth is cutting open some poor women’s hoo-ha a better surgical choice? I mean maybe–MAYBE–said female works as a swimsuit/lingerie model, but even then, if that’s her professional job, she’ll have professional makeup artists to cover the tiny-ass scars.

But wait, there’s more:

Surgeons Santiago Horgan and Mark Talamini made a small incision in the wall of the patient’s vagina, through which they passed surgical tools and a small camera to the appendix, removing the organ through the same incision. Surgeons also made a small cut in the bottom of the patient’s bellybutton and inserted another camera through it to help guide surgery. The procedure took 50 minutes from start to finish, 20 minutes longer than a standard laparoscopic appendectomy.

Wha?! So they made an umbilical incision anyway, just like lap, so this magically wards off the evil spectre of herniation…how? And almost doubling surgical time is ALWAYS a plus…good going guys! (Note that an open appy is probably 15 minutes for someone who wants to book it out of there (maybe less–never been at a clocked speed test case), tripling the time.

But let’s now turn to that first quote and change the patient to a man. Say a young, otherwise healthy male presents to an ER with an acute abdomen, rebound tenderness, McBurney’s sign, the works. Cocksure eager surgeon dude comes and offers the poor guy a “minimally invasive” option–going through his ass. Last I checked, having a trocar sticking out one’s ass as all these scissors, cautery, etc. get shoved in en route to the appendix (is this in a right decubitus or a jackknife position here, anyway?) is about as invasive as you get.

Yes, the total instrument travel distance in this case is pretty short, and if there’s no serious shit going on, it probably is technically a more direct approach than going through layers of muscle, fascia, etc. Again, I appeal the the surgeons to educate me on basic surgical points here, but isn’t an immediate entry into the peritoneum via the GI lumen–and specifically the rectum of all places–just presenting a contamination problem right away? Yes, there will be abx irrigation, but going through the gut lumen for starters just seems wrong from an aseptic technique POV. Dunno. The whole thing is whack, which is my whole point, so there.

And now, back to our regularly scheduled program

I’m back!! I missed blogging tremendously with so many times thinking in my head, “Oh, I gotta write/share that!” but I made a commitment to let things settle down to a dull roar before I started posting again, not wanting to have this start/stop bad mojo on the blog. Thankfully, I think I’m finally at the point where I can say things are calm enough and look like they’ll remain so, at least as much as I can expect. So much to tell, so much I’m glad is in the past, so much to look forward to–all in good time.

For now, here’s a small list of some general comments to catch you up, in no special order (some of which will be expanded on later):

• I got some email wondering if my “Hiatus” post indicated I was going to seek psychiatric care or the like. Funny that, because I did actually call around to see what was available. Unfortunately, there isn’t anything available for “crisis counseling” on an outpatient basis for people who need short-term, more focused help but are functional otherwise. Therapists and psychiatrists are backlogged for weeks or months, so “emergencies” here are handled by inpatient programs akin to the state ward where you get to use crayons and clay for art therapy and ice cream snacks are used as rewards for good behavior. Um, no thanks.
• Instead of mental health care, I got treated to some hard-core health care: 2 hospitalizations with a sum total of 15 days inpatient stay involving multiple scopes, surgery and blood transfusions–oh my! (definitely much more on this later) I’m still on pain meds as I heal, so pardon the grammer and mispellingses for now.
• Shortly after I arrived in TX, I treated myself to a Blackberry Curve 8320 now that I was stateside and my cell contract had long expired, ripe for cheap equipment renewal. No more living in the Mexican data desert! (Actually GDL is totally wired for 3G–it’s just that there, the “3″ means you have to pay 3x as much!) Having mobile email and browser is schweeeeeet.
• In just the span of a couple of months, my daughter seems to have grown up so much, yet she’ll barely be two next month. It’s awesome seeing her slowly develop every day into her own person. It’s also clear to me that all the trauma we’ve gone through seems totally lost on her–as it should be–as I watch her happy as can be with the simplest of things. I’d go through 100x more just to make sure it stays that way.
• I still haven’t decided what do call my new domain (since Mexico Medical Student is obviously not applicable anymore). I am tending to pick a generic title that has nothing to do with medical school, just because I want to be prepared for anything, and more to the point, keep using it after medical school. I want to be happy with something long-term and not have yet another migration later.
• It’s nice to have TiVo actually doing what it’s supposed to do now that it can actually use US programming data. I watch so little TV anyway, but what I do watch, I’m fiercely addicted to. Right now that means Top Chef and Battlestar Galactica, both new seasons recently started. In Mexico, I used to always download and watch episodes in large chunks after-the-fact; now it’s almost torture waiting week by week like everyone else for what’s next.

Well, that’s pretty much enough to get an idea of what’s going on. Other than the medical stuff that will follow, there’s not been much. I do have to make one very important point to close this post, however. A few friends have asked how school search/applications are going, completely because they cared and wanted to know. On the blog, however, I will not be posting anything about any facet of any applications, status updates, prospects, etc. Medical school application is a rigorous and, frankly, competitive endeavor. There are enough lookie-loos from my school who (for reasons also to be written about) are in the same application pool as I, trying to transfer to other programs. I don’t need to divulge what I’m doing for obvious reasons. If anything is shared, it’s pretty much because something is a done deal well after-the-fact. Since my target is August, that means mum’s the word for a good while. I hope this is easily understood. Thanks.