You Are My Sunshine

45yo M h/o CP, nonverbal, and neurogenic bladder/bowel s/p multiple abdominal surgeries including colectomy w/ end ileostomy came to our service due to septic shock and lactic acidosis from presumed UTI. This morning, his belly was definitely distended but soft, lactate seemed to be trending down, so decision was made to just watch him and get a STAT CT abd/pelvis w/ PO contrast (couldn’t give IV, elevated Cr). For some reason, CT never ended up happening. Decision was made to go to OR in setting of terrible ABGs (pH of 7.056), again another “for some reason,” bicarb was never given. We didn’t know the pt’s baseline MS, but he just didn’t look comfortable at all – he was squirmy and moaning quite a bit. Bad prognosis with acidosis that terrible, anesthesiologist was saying he hadn’t seen a pH that low in a long time. Evidently, the last time the patient was at Regions, he smiled a lot whenever anyone started singing, “You Are My Sunshine.” So while we were waiting for him to get intubated in the OR, we all sang a round of the chorus then put the song on repeat over the OR speakers. I was at his side, holding his hand, holding back tears – fearing the worst for him. Eventually we were able to stick a camera into his belly, but we quickly converted to open when we couldn’t see shit. As soon as the laparotomy was made, his swollen ischemic intestine pushed its way out into the air. I’ve never seen anything like it – his small intestine looked like an angry purple snake writhing within the hands of the surgeon. And I’ll never forget that smell – the smell of dead bowel. “Midgut volvulus with necrotic small intestine from ligament of Treitz to ileostomy – minimal improvement in perfusion with detorsion. Based on intra-op discussion w/ pt’s POA, no bowel resection was performed, and pt will be made comfort cares.” Chart checked him this evening, found out he passed away. RIP, sunshine.

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GS/CRS

Pretty awesome service so far – as an intern, I essentially manage the colorectal surgery service and cover whatever cases the chiefs don’t want. I was even able to take a 2hr nap today because I didn’t have any cases to cover.

Hmmm, interesting cases… 50-some yo F tried to get colonoscopy on Monday of last week, they couldn’t get through past a stricture, so she got a CT colonography. That unfortunately showed carcinomatosis (aka peritoneal metastasis), and omental/peritoneal biopsies just came back as adenocarcinoma of pulmonary origin. She used to be a 20 pack year smoker but hasn’t touched a cigarette in 20 years; she’s basically otherwise asymptomatic other than recent constipation.¬†Staff thinks the path is wrong, that it’s actually ovarian in nature… We’ll see what comes of it; she’s scheduled to see heme onc tomorrow. Hoping for the best for her.

Also, if an otherwise healthy patient hasn’t pooped in over a week and has obvious stool burden on imaging, get CRS involved early and have a low threshold for surgical intervention.

ACAPS Plastic Surgery Boot Camp

Definitely a positive experience, if anything for the opportunity to get to know my fellow co-interns in plastic surgery. Going backwards – had an amazing dinner at Eddie V’s in La Jolla, sponsored by one of the many sponsors of the Boot Camp. Killer view, good food, great company. I particularly got along well with the LA residents (USC and UCLA). Learned a lot of crap today – did “microsurgery” on penrose drains, Z-plastied a pig foot, attempted cleft lip markings, did a Z-plasty cleft palate repair on towels, put in arch bars, plated skull fractures, placed thumb spica and sugar-tong splints. Also learned how to effectively read a trauma max/face HCT. Busy ass day. Oh and we were provided delicious tacos for lunch, another sponsored meal.

On a separate note, my lower back has been killing me lately, to the point where I can’t properly bend down or over anymore. I have to lower my body with my knees. I don’t know what the hell is going on, but it better remediate itself quickly before I start my gen surg rotation on Monday.

Fuck that Call Night

Not a wink of sleep. 4 TTAs in the span of 15min, meanwhile pt crashing on floor requiring rapid response and transfer to SICU. Oh and I got chewed out by a rather ornery ophthalmologist who I consulted for a direct transfer at 1am – I think I handled the situation tactfully, though I probably pushed back a little more than I should’ve as an intern. But the fuck dude, what do you want from me… My attending personally asked me to consult you as soon as the pt hits the floor. Calm the fuck down. Whatever, I was over it before it even happened – I was due for one of those anyways. My first angsty consultee was ortho at the U, and they ended up doing a bedside debridement of a subungual abscess. Learning points though: get acuity, IOP, and… Shoot I forget the third thing he wanted. EOM maybe? I don’t remember.

Point: Intern

Finally, first-hand experience that attendings can be wrong. TTA – 22yo F driver of vehicle, probably unbelted, T-boned by dump truck going 45mph, launched into passenger seat. +LOC. Tachy to 130s but otherwise VSS, GCS 12. -FAST, -CXR, -Pelvic XR. Only obvious deformity is what was thought to be a scalp/forehead lac. Attending decided to forego HCT (because of… Well… I’m not sure why, actually… I think maybe because he thought GCS was 15?) and basically scan everything else. CT abd/pelvis normal, CTA normal, CT spine showed C2 transverse Fx, possible C3 Fx. Paged PS for scalp/forehead “lac” and NSGY for C2 Fx. Went back to trauma bay, met up w/ PS. Basically discovered that she was essentially scalped – pt was pretty disoriented upon further questioning (only oriented to self but couldn’t even remember her own birthday), GCS of 13 (4 eyes, 4 verbal, 5 motor). Despite pt already having had received contrast, I decided to get HCT anyway to assess for bleed given disorientation and the fact that the MOI was severe enough to separate her scalp from her skull (and PS wanted max/face). Lo and behold, HCT showed R parieto-occipital & L parietal SAH, intraventricular hemorrhage, SDH. Point. Intern.

Lessons: (1) Go with your gut; (2) Always suspect injuries are worse than they look; (3) If the MOI is bad enough, image.

Also, update on that 82yo lady – she ended up with a very uneventful hospital course, went to TCU. Seems to have very supportive daughter. Happy ending, I think. Will continue to cross fingers that the lung mass is nothing.

Trauma Sucks

Needless to say, I’m not a fan of TACS. I like the trauma, I love my coworkers, but I cannot stand this service. At. All. It’s like being an IM res + SW rolled into one.

And I’ve also discovered my soft spot. I can’t handle when old grandmas and grandpas get hurt. We had a TTA last week, 82yo F ped vs. MVC, and it took a LOT for me to hold back tears. She was totally fine, GCS 15, dislocated shoulder was probably her worst injury, but I couldn’t stand to see her in a Miami-J, practically restrained on the ED bed. I probably spent more time by her side, holding her hand, than any other TTA that has comes in. Incredibly sweet lady. To make matters worse, incidental finding of lung mass on CT. Probably not cancer, but still.

At least I’m getting positive feedback about my performance so far during intern year. I’ve got decent bedside manners, and I’m evidently pretty good at patient management.

And I will say, there is one good thing that has come from this rotation – I learned about an opportunity where I can be a mentor to young girls caught up in Latino gangs throughout St. Paul. I’m really really excited to start getting involved.

Less than 2wks left. Man oh man.

TACS

Almost done with week 1 of trauma surgery at R. I gotta say, so far it’s just like being a glorified internal medicine resident. Or being an adjunct service to social work. At least I’m working with some pretty excellent residents. I really like my 2nd year residents – Sara and I are going to try to make global surgery have more of a presence here at the U. And my co-intern is a hoot – we go back and forth with plastics vs. ortho razzes pretty much on an hourly basis. Oh and our PA on the service is a grade-A badass. All these things make things bearable.

First TTA today (trauma team activation). 74yo M, unknown PMH/PSH/meds/allergies, brought in by EMS after sustaining fall from scooter. Was trying to make a turn and evidently fell on pavement. LOC 3min. GCS at scene was 14, A&Ox3, 190s/100s w/ nl HR & RR. My job as MD #2 (ED res is MD #1, and trauma surg junior res is team leader) is “E” for exposure. I cut off all his clothes and look for obvious injuries throughout his body, take his peripheral pulses, look for neuro S+S. This guy had abrasions on his elbows and knees bilaterally, more prominent on his left side, and what appeared to be a hematoma on the lateral aspect of his left elbow. Had abrasions all over his face, dried blood in both nares, deviated septum to the right. Hematoma on left anterior scalp. So, ABCDE – Airway fine, he was talking to us. Breathing fine, no signs of TPX, oxygenating well on RA. Circulation ok, definitely hypertensive, extremities WWP, peripheral pulses intact. Disability meh, he seemed quite confused (verbal was 4). Already talked about Exposure, not sure if he was intoxicated or not, not sure if he was helmeted (judging by his injuries, probably not). Negative EKG, CXR, FAST. After initial stabilization, pt went to get head/spine CT w/o, initial read showed small right ICH, punctuate bleeds throughout but more prominent in right, left skull Fx, multiple facial Fx. Cervical spine ok. Proceeded to get face/mandible CT. Consulted NSGY who recommended SBP <140, HOB >30, repeat HCT in 6hrs (before actually seeing the pt). Not sure if he’ll be admitted to the floor or ICU – all depends on BP control. I’ll find out tomorrow if he needed a nicardipine drip (= ICU).

Last Day of MIS Tomorrow

Last day of my first rotation tomorrow. Some notable patients:

  • NH: Basically all started w/ a perfed diverticulitis. Underwent multiple washouts, dehiscences, fistulas. Moral of the story – think twice about taking down enterojejunal fistulas. Guess it’s a rare thing to see a pt not intubated with an Abthera, but pt is somehow is able to handle. Woof.
  • TK: DS to CCL. Don’t underestimate the importance of nutrition. Malnourishment = bad immune system = impaired healing.

Hmmm, what other takeaways? I guess not much. Regions Trauma starts Monday.

B/O?

Uh oh. Could it be that I’m already experiencing mild symptoms of burn out? I haven’t even finished my first rotation yet. Maybe it’s the impending doom of being on call all weekend. Or maybe it’s being sick of not knowing everything yet (and don’t worry, I’m fully aware of how preposterous that expectation is this early on). Or maybe it’s having found out that 2nd year is the worst year by far. Orrr maybe it’s simply that I’m on my period this week and am therefore just more tired in general. Whatever it is, I definitely felt a sniff of a whiff of burn out.

Little things help though, like having patients compliment me on my bedside manners. I guess I’m pretty good at that.

Oh and I ran into my old facial plastics PI in the hallway the other day, and we got to exchange some excited jibber jabber about the smile paper we worked on. I contacted her later that night to see if she’s got anyprojects that I could help out with – she’s doing some pretty cool stuff that’s tech-related, so I’m excited to dig into that.

Not much else to update. We have two 3rd year medical students on our team now. I enjoy having them on our service; having med students definitely reaffirmed my love of teaching and mentoring.

I was able to go home last weekend for the first time since starting residency. Oh my goodness, I can’t believe I forgot to talk about this – my parents basically did their own version of coming out to me, and they told me that they fully support me and love me no matter what. I’m actually still in shock from that conversation. I was 100% certain that that would NEVER happen. Some context – I set extremely low expectations after deciding to come out to my parents on their level of acceptance. As in, I expected them to take a while to start talking to me again. And I would’ve been completely ecstatic if we conversed in our usual manner (I joke with my parents a lot), fully expecting to never to bring up the subject of me being gay again. But not only are we back to talking like we always did (within like a day of coming out), they actually THANKED me this past weekend for bringing LGBT issues to their attention. It was a paradigm shift for them – that’s how they phrased it – the concept of LGBT being ok within the doctrine of Christianity. The way they see it, God made me the way I am, and that isn’t, shouldn’t, be a sin. I wish I would’ve videotaped the entire encounter, because I never want to forget that moment. I will cherish this past weekend home for the rest of my life. Not everyone who is gay is nearly as lucky as I am – I am so fully aware of that – especially in a Korean and Christian family. But my God, am I ETERNALLY grateful that I am this lucky. I can’t imagine what my life would have been like without the love and support of my parents, because my parents mean everything to me. I owe everything to them. Everything.

Ok, recalling that memory actually made me feel a little better. I’m still feeling a little burned out, that I can tell for certain, but I definitely feel better about life in general. See, so much to thank my parents for.