one of THOSE days...

After spending last week at the Coronary Care Unit (more about that experience later), I was very excited to re-join my Internal Medicine team for Week 6/8 of inpatient medicine. I was ready to start following some new patients as today was our call day, which turned out to be a 14+ hour call day.

My first patient was a very nice gentleman who had had a rough time with addiction issues in his middle-aged years but seems to have cleaned up his life quite a bit since then. He has been HIV+ for 20+ years and has been on anti-retrovirals since then. He is doing very well in that aspect of his life. He came in with a very non-specific complaint of some pain in his left arm that bought him a chest x-ray in the Emergency Department. The x-ray results bought him an admission into the hospital - something he was not too happy about, and a CT scan of his chest.

My resident, intern and I walked into the radiologists' office to get a read of his CT scan. Somewhere within us, all three of us knew what to expect. The CT scan confirmed a very high suspicion of a primary lung cancer in my patient. This can't be confirmed until a biopsy of the mass is done, but the radiologist was pretty sure this will turn out to be malignant - Here's hoping he is wrong.

We also wanted the radiologist to read the abdominal CT scan of my fellow medical student's patient. It turns out that that patient had the classic signs of metastatic ovarian cancer on her CT scan.

In a 5 minute visit to the radiologist, we bought ourselves 2 high suspicion scans for malignant cancers.

The universe was not done yet. My second patient was a very nice old lady who came in with some very non-specific complaints that had bought her a chest x-ray at a different urgent care center. The results of that chest x-ray bought her a visit to our Emergency Department, and a CT scan of her chest. I didn't have to go to the radiologist's office this time. The report was already in the system. Our patient had a humongous pleural effusion (fluid in the membranes surrounding her lungs) with a high suspicion that this was caused by metastatic cancer that had spread to her pleura. We will tap the fluid and analyze the cells in the fluid to see if it is malignant or not.

Neither of my two patients have a confirmation of malignancy yet, but if clinical suspicion is anything to go by, that might be changing tomorrow for both of them.

This was definitely one of those days. Yes, one of THOSE days.

List of Gyn Surgeries

The following is a summary of the surgeries I happened to see over the 2 weeks of Gynecology. The number after shows how many of each procedure I saw.

1. Tension Free Vaginal Tape Obturator, Sacrospinous fixation - for urinary incontinence - 2
2. Laparoscopic Bilateral Salpingo-Oophorectemy - Removal of both ovaries and fallopian tubes
3. Laparoscopic Assisted Vaginal Hysterectomy - 2
4. Laparoscopic Right Salpingo-Oophorectemy - The right ovary had a cyst about the size of a human head. We sucked out the fluid and the cyst was very easily removable after that!
5. Total Abdominal Hysterectomy with Bilateral Salpingo-Oophorectemy - with staging for cancer - thank goodness, there was no evidence of malignancy!
6. Total Abdominal Hysterectomy - 3
7. Total Vaginal Hysterectomy - 3
8. Laparoscopic Assisted Vaginal Hysterectomy - 2
9. Laparoscopic Assisted Supra-cervial Hysterectomy - You leave the cervix in
10. Exploratory Laporoscopy/Left Salpingo-Oophorectomy
11. Wide Local Excision of Breast Mass - benign mass
12. Partial Left Mastectomy
13. Dilation and Curettage - common diagnostic and therapeutic procedure for uterine bleeding, once for endometrial ablation for heavy menstrual bleeding - 3
14. Large Loop Excision of the Transformation Zone - pap smear had shown high grade abnormal cells in the cervix

Search here for more details of some of these procedures:

2 weeks of GYN surgeries

After a great week of night float on my Ob-Gyn rotation, I was due to spend 2 weeks in the OR helping with gynecological surgeries. I was very excited about this. One of the big decisions you make in medicine is whether you want to go into a "medical" field or a "surgical" field. I have yet to make that decision, mostly because I haven't had enough exposure clinically. The 2 weeks of Gyn would be a sneak peak into surgery.

Despite passing out in the OR during my first C-section, I wasn't too nervous about being in the OR. I had already been in on a few more C-sections and was getting used to that atmosphere. Scrubbing into the OR was becoming more of a habit. This includes scrubbing our hands and arms for 5 minutes to make sure that we are completely clean and maintain sterility in the Operating Room. The harder part is gowning up and gloving up while remaining completely sterile. Thankfully, most of the nurses were very helpful with this, and by the end of the two weeks, I felt more competent with the art of scrubbing. This is not me below but we looked something like this while getting ready for the surgeries:


Most of the surgeries lasted anywhere between 30mins - 2 hours and were really enjoyable! I got an opportunity to scrub in with residents who were accompanied by teaching faculty members as well as private attendings (highest on the totem pole in medicine). I was pleasantly surprised by how much almost each and every one of the surgeons was interested in teaching. They took the time to show me anatomic structures. They took the time to ask me questions about the anatomy. The really good ones took the time to get to know me better and give advice on how to go about the 3rd year of medical school, and how to balance personal lives with careers. I was also very lucky to work with excellent residents who had a wonderful attitude towards their patients and showed great skill.

One of the final year residents especially sticks out in my mind. Her laparoscopic technique was simply brilliant. I would say that her skills were so developed that they would probably rival most attendings' skills. Not only that, but she knew how to make laparoscopic procedures interesting for me as a medical student. We don't get to do the actual procedure so it can sometimes be hard to stay focused looking at a video screen for 2 hours. However, this particular resident described each step as she did it, engaged me throughout the entire time and really made the time fly by. I am very thankful for seeing her teach and hope to emulate some of her techniques once I am on the other side. (of course, that is if I end up going into a surgical field)

As the two weeks went by, I got to see a large variety of cases (listed in the next post). I would be very excited to wake up every morning to be in the OR. I had a lot of fun talking to my patients before the procedures. Although they were nervous and scared, they had this faith. Faith in their surgeons that whatever problem they had would be fixed after the procedure. Faith in their anesthesiologists (whom they only met for a few minutes), that once they went under, the anesthesiologist would take care of their breathing and their basic physiology.

I did not expect this. I absolutely LOVED being in the OR for the 2 weeks. Whether it was the adrenaline of being there and seeing awesome procedures done for the first time, or whether it is a sign that a surgical field is calling my name - only time will tell.

My first C-section - and yes, I passed out in the OR...

It was the second night on night float, and it was some time around 11pm. I was working with the resident that was scheduled to do any emergent C-sections that night. I was super excited. This was going to be the first one that I would see and help with.

The nurses were great in showing me how to scrub in properly. I had scrubbed in for a laparoscopic procedure the previous night but I was still very shabby. I didn't have time to introduce myself to the anesthesiologist as he was in the middle of taking care of numbing the nervous looking woman.

The chief resident (probably the best resident teacher I have worked with to date) and the 2nd year resident were the ones doing the C-section that night. My role as the medical student was going to be to help with suctioning (estimated blood loss for most C-sections is >500cc), help holding bladder blades (to make sure that the bladder is out of the way when cutting into the uterus) and a few other things. As with most surgeries that I attended, my residents taught me by asking questions about the anatomy, and by showing me structures that were needed to be identified. I was very comfortable in answering "I do not know" to any question that I had no clue about. Never having seen a pelvic surgery before, this was the most frequently used answer. The residents did not even once make me feel as if I were incompetent or stupid. They were extremely supportive.

The room was getting quite hot as time went on. The lights in the operating room get very hot, very quickly. At baseline, I get hot very easily. I grew up in Tanzania, at the equator, but my hometown is 5000ft above sea level, meaning that the weather there never got unbearably hot - and that is my reason/excuse for feeling hot so easily. But I digress.

I was really enjoying this C-section. We had gone through the abdominal layers, and through the uterus. The baby was born. A tiny and very cute looking young girl was brought into this world. I continued to hold down the bladder blade, while trying to soak in the entire experience. 45 minutes or so had passed by at this point. The next thing I knew, the chief resident, who was standing next to me, was tapping my shoulder and telling me to let go of the bladder blade. She was asking me if I was ok. She was telling me to take a seat. And then it hit me.

Did I just pass out in the OR?

Am I THAT med student?

The anesthesiologist was pulling up a chair for me. He told me that I could take off my gown as it would make me feel better. Of course, all I was saying at this point was "I am doing fine, and I am so sorry - I think it just got too hot for me." And I was doing ok at that point. I felt cooler and I felt better. But clearly, it had already happened. At some point, I guess I got too hot and didn't realise what was happening, and had a syncopal episode.

On a scale of 1-10, I was about a 15 in terms of how embarrassed I was.

One of the nurses took me outside as it was much cooler there. Although I felt better at that point, it was the right thing to do. The nurse gave me some apple juice and a little snack. All I could think of while drinking the juice was a) I hope the patient is doing fine and I didn't do any harm and b) Wow, did that just happen?

20 minutes later, I decided to go back into the OR and see what was happening. The residents were just finishing up. All seemed well and that was very calming. They were finishing up the surgery.

I still had no clue as to what had happened. Upon asking my chief resident, this is how the story went: I started leaning onto my chief resident. She told me that some medical students do that to get a better view. But supposedly, she did not expect me to do that, and immediately thought something was going on. The resident across from me tried calling my name but I was not responding. They had then realised that I was about to pass out. They tried to get me to release the bladder blade, but being the dedicated med student I am (cough cough), I wasn't letting go of the blade. That is when I finally recovered and heard my chief resident's voice. The entire episode lasted 45 seconds or so. I continued to apologise as I felt terrible about the incident. The chief resident then went on to tell me her story about when she passed out during her surgery rotation in medical school. The 2nd year resident then shared her story. And then both residents took the time to ensure me that it was not unusual for this to happen.

At about 3am that night, four hours since this incident, I was back in the OR with the same 2 residents helping out on another C-section. They taught me just like before, as if nothing had happened. The asked me questions, just like before. The same anesthesiologist gave me a friendly nod. I saw a full C-section, from beginning to end, with no interruptions this time, and it was awesome.

Gosh, I love medical school!

Ob-Gyn Week 1 - Night Float

We get to spend one week in the Triage area (aka Emergency Room) of the women's hospital during our Ob-Gyn rotation. This happened to be next for me after a great clinic week. We had lecture from 4:30-5:30ish and worked from 6pm-5am ish for the week. We worked with the same team for the entirety of the week (I worked with a different person every day at the clinic). We had a fantastic team that week - the residents and interns were great teachers and my fellow medical student (a 4th year that was sure she was going into Ob-Gyn) gave some very useful advice about rotations in general.

I spent several nights working in the Emergency Room during my first 2 years of medical school. My community mentor was great and I loved the variety of cases I got to see in the ER then. The night float week was no different. I got to see patients with a variety of complaints - some presenting with pre-eclampsia, other with bleeding in their first trimester (and understandingly being very scared by it) and then there were the mothers that were very close to delivering their baby and were feeling as if they were having contractions. It was always sad to inform the mothers that their contractions weren't regular enough and that they would have to come back another time. They were not yet in labor. Yet, the pain that some of these women were in was quite unbearable for them. It is amazing how a husband's or family's support went so far in relieving this pain.

Another great thing about the night float week was that I got to scrub in on emergency C-sections. Before this week, I had never scrubbed into any surgery. I had never seen a C-section done. I had never seen a baby being delivered. And by the end - I had seen 3 C-sections and helped with 2 deliveries. Oh how amazing it is to be a part of bringing new life into this world. The feelings that I went through when were simply amazing. I felt very lucky. As disgusting as the thought of amniotic fluid and blood all over the room is, the joy of hearing that new born baby was simply priceless.

In a nutshell, the week flew by. And I couldn't have asked for a better night float week. My sleep schedule was all messed up by the end but that didn't matter. I had learned a ton and I had developed great rapport with the residents that had taught me that week. Most importantly, I saw C-sections and helped deliver babies!

Ob-Gyn Week 1 - Thoughts on Clinic Week

The patient population at the clinic was very diverse ranging from Caucasian patients to Hispanic patients to Immigrant patients from West Africa and Central America. Patients presented for a variety of reasons some of which are:
- care during their pregnancy weeks (antepartum care)
- general clinic visits for infections, contraception, bleeding
- annual visits
- 6 week postpartum visit

I spent an afternoon at the Colposcopy Clinic. This was an interesting afternoon. Wikipedia says that colposcopy "is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix and the tissues of the vagina and vulva." This procedure is often done if a pap smear comes back abnormal (There is a long algorithm that is used to determine if a woman needs a colposcopy or not). 3 out of the 4 women who were undergoing the procedure did not want a male medical student in the room - which was a little disappointing but understandable. After reading about the procedure and looking at atlas pictures for most of the afternoon, I was glad I got to see one procedure being done. It was relatively simple and short (and normal which was excellent news for our patient!).

In a nutshell, I loved my clinic week. I enjoyed providing primary care to patients and was very impressed with the preventive health opportunities that were created and acted upon in the clinic. Pregnant women come to hospitals and clinic often for care, and this gives them access to the health care system. It is our responsibility as physicians to take advantage of this - and the staff at the clinic definitely did that!

Ob-Gyn Week 1 - Clinic Week and Physical Exams

We spend one week in the clinic at our hospital during the Ob-Gyn rotation. I was glad I had this week first. It would allow me to ease into my first clinical rotation. During our first 2 years of medical school, we learned how to obtain a full history and perform a full physical exam on our patients in our doctoring course. If anyone disliked this course during the first 2 years, I am sure that they quickly gained a whole lot of appreciation for the doctoring course.

I worked with an intern during my first morning in clinic. I wouldn't have wanted it any other way. Interns are closest to being a medical student, and mine remembered her first day "on the wards" very well! This meant that she did a great job of easing me into this rotation. We went over some of the specific questions to ask when obtaining histories from a pregnant lady. This was good as we had not previously learned this.

We had also learned how to do breast and pelvic exams in doctoring. I am really glad we got a refresher during our first evening as it made me a little bit more comfortable doing them. We are trained using standardized patients. These are people who get paid to act as patients, and we get to practice performing exams on them. A (fantastic) nurse practitioner guided us through the steps and the standardized patient was an excellent teacher too. By coincidence, my standardized patient was the same one I had trained with about 6 months ago, and we both recognized each other and gave each other a courteous shake of the head to acknowledge that we both remembered each other. I didn't expect to have the same patient - at all.

During the clinic week, I got to perform a lot of physical exams, and each and every single time, I was extremely careful to be very professional while doing the exams. This both helped calm my nerves and calm the patient as well. Most patients were ok with having me as the medical student perform the exam under the guidance of the nurse practitioner. A few were uncomfortable and I happily agreed to their request of letting the nurse practitioner perform the exam. As a male medical student, I can see why some females would be uncomfortable in letting me perform a pelvic exam. I am very grateful to those patients that let me perform the exams. They have been a part of some of my most nervous moments in my medical education.

Back after a long hiatus...

It's been a while since I have posted on this blog and a whole lot has happened since May! Not only have I finished my Ob-Gyn rotation, but I also went home to Tanzania for 6+ weeks where I gained 13 lbs from fantastic home-made Indian food (I will lose it very quickly so I am not too worried), did a 4 week rotation in Dermatology in Tanzania, and am now done with 4 weeks of Internal Medicine!

I plan on writing more frequently and will have a few posts over the next couple of days regarding my experiences over the past few months.

I haven't had a day off for the last 2 weeks, and have thus attained a whole new appreciation for my 3 day weekend. Thank God to Labor Day Weekend!