Gyn/Ob

Aaah...sweet sunday comes to an end. My extremely short weekend was filled with sleep, eating lots, studying and taking unnecessary naps in front of the fire place...not working on weekends has been great!
So I am 3/4 of the day done with my obstetrics and gynecology rotation, and as you all can see below...it has been a minute since I've written. Let's just say that I've been dazed over the past few weeks since I was on night shift for OB. I give mad props to people who have chosen night shifts because it takes so much out of you. Not only is your sleep cycle messed up, but your meals take a turn for the worse along with your entire routine. I guess if you're doing it for longer than 2 weeks, its ok; but man all I've done for the past two weeks is sleep through the day, wake up to shower and eat, go to work---and REPEAT.
But all is well since I have really enjoyed my OB rotation thus far--more than I had expected. For those that know me personally, know that as much as I like children...anything related to pregnancy freaks me out. From the growing belly, to the fact that this little alien is basically sucking the life out of you!!! However, my first experience delivering a baby was amazing. I was about 17 minutes into my first night on the service, when the intern flags me down and tells me to go get a surgical cap and booties on. We rush the mother into the OR for a stat Cesarean delivery. I get scrubbed in (nothing different from surgery or even gynecology) and stand next to the attending with the patient draped and ready to go. The intern makes the cut and the procedure begins just like any other surgery-cut through the skin, abdominal fat with short bursts of cautery to stop bleeding, and then through the fascia. We then get to the abdominal muscles and cut and pull those apart. At that point...everything was normal...I honestly didn't feel like any sort of delivery was even going on! I must have blinked for too long, because the next thing I knew, my hands was being taken into the abdomen and being placed on some soft, sort of rounded part of the body. Naturally, I figured it was the uterus, and the attending was trying to get me to pull it up and out of the body. WRONG! They had already made a slice into the uterus and my hands were holding the head of the baby. How did I figure this out?? Well when I was being yelled at to start pulling...haha. I managed to get the head out and slipped my hands under its tiny arms to pull the rest of its tiny body out. Ignoring the blood and fluids leaking out of this lady's body, I felt a lump in my throat and tears welling up in my eyes. I had just brought a new life onto this planet! I am and always will be the first person to touch this little child and bring him into the world. I look back now and think about how sappy yet magical that very moment was and I smile every time :)
As the baby was out, I kind of just looked around the room and people were running around trying to arrange for the next few minutes. I looked down and all I saw was this tiny human being crying, wiggling his hands and feet as we prepared to cut his umbilical cord. Snap..and he was now detached from his mother. The scrub nurse quickly handed him off to the circulating nurse who wiped him down and handed him off to the pediatricians. And like that...it was over. The procedure then ended up being pretty similar to the other surgeries. Close up the uterus, push it back in, allowing it to naturally place under the bowels. Close up muscle, fascia, and then a subcuticular to close up the skin.
So that was it...! My first delivery. The night continued with excitement...just as every night afterwards...with more vaginal and cesarean deliveries.
I was getting used to my schedule...but now starting days tomorrow..err..today! Lets see how that goes. Adios for now :)

Ganglion cyst

My apologies for being MIA. As some of you may know, I got into a bit of a situation exactly one month ago involving a traumatic injury to my wrest. Unfortunately, that required me to take medical leave...so surgery was left in the middle. I'll be completing it later this year. BUT, I did get to see quite a bit of surgeries before I took time off. Because my injury is focused in the region of the hand and wrist, I'll be describing one of the surgeries I witnessed before taking leave: a ganglionectomy.

To start off, lets review some anatomy. See the pic below to avoid confusion. Starting off with the bones of the forearm: ulna (close to the pinky) and radius (on the side of the thumb). The bones of the hand are a bit difficult to remember, but I think of it as three different sections - the base being composed of the carpals, metacarpals make up the palm, and phalanges make up the fingers. Take a look at the pictures(http://www.graphicshunt.com/health/images/hand_bones-1318.htm) for a visual understanding. Now lets talk about the meat, haha, by that I mean muscles. Since they're a bit difficult to put out in words, lets just stick to the pictures. Lets move onto the topic of the day.

Ganglion cyst. What is that? Well...........here is the 411 on this medical condition.

What: fluid-filled swellings around the tendons and joints

Where: usually in hands and feet but can be located near any joint

Why (aka Cause): definitive cause is unknown, however studies suggest trauma to the joint or an anatomical anomaly in joint capsule or tendon sheath [creating a one-way valve that allows joint fluid out of joint but not back in] could be possible causes.

Symptoms: most cysts are raised, round lumps that can vary in size. Usually asymptomatic, hardly painful. However, the cysts can cause pressure on nearby nerves creating pain/weakness/numbness

Tests & Diagnosis: Physical exam, X-ray (to rule out other conditions), Aspiration (to confirm diagnosis by drawing out fluid in cyst), other Imaging tests (MRI, ultrasound for location, size, shape and depth)

Treatment: if ganglion cysts are painless, no further treatment is required. Its a watch and wait sorta thing. However, once the cyst becomes painful and starts interfering with one's daily activity, then can you think about some treatment options.

• immobilize - to prevent further growth of the cyst and possible shrinkage. By limiting movement, pressure on nerves can be relieved.
• aspirate - drain fluid from cyst with steroid injection following to prevent inflammation. With this treatment, the recurrence rate can be up to 60%
• Surgery - Ganglionectomy - outpatient procedure involving the excision of ganglion cyst usually under local anesthetic, perhaps even general reserved for cases with chronic pain

Ganglionectomy - my experience:

Probably the quickest procedure I saw in the 20 or so days of surgery, we were literally in and out of the OR. I think scrubbing in took longer than the actual removal of the cyst.

Initially, the patient is given general, regional, or local anesthetic to relax muscles and fall asleep. In this case, it was the removal of a large ganglion cyst of the dorsal wrist, so the patient was given general. The procedure was done by a plastic surgeon who made the incision right through the center, complete length of the round cyst; just after palpating the borders. She then separated out the extensor tendons and found the ganglion cyst in close proximity to the radial nerve. The difficult portion was excising the base of the ganglion cyst which was almost attached to the radial nerve. It was key that we get the stalk of it, because the recurrence rates can be quite high. So, once the cyst was out we got to feel it! It felt like a squishy but somewhat firm ball of white goo. Afterwards, stitches were put in and patient was wheeled out. Quick, somewhat easy and simple. Here are a few pictures! Enjoy :)

Surgery!?!!?!??!?!?!

So...as some of you know, I've started my surgery rotation, first month at Harper, next month at DRH. I've been interested in surgery for quite some time now, and took part in a 'clinical skills course' for surgery rotations and also interned at Henry Ford over the summer in their surgery program. However, nothing comes close to the wonderful [please note that italics in this case indicates sarcasm] experiences in the OR as a third year medical student. Not only are you waking up at such ridiculously early hours in the mornings, but you're at the lowest level of the totem pole. Actually, that's a lie...a third year medical student is not even a part of the totem pole. As a third year, you're squished below others on the totem pole to such an extent that no one wants you to be seen because you're a disgrace to all the activities you attempt to do in the OR.

Ok...so that was a bit dramatic...and exaggerated, haha. But jokes aside, surgery is sooooo different from neuro and psych. There's this unique essence that lingers in the hallways of the OR. It makes you feel stronger, smarter, and better than everyone else (aka non-surgical peeps). In my 3 (yes..only 3) days on this rotation, I've felt myself being utterly intimidated, yet at the same time, wanting to fit into the field.

I scrubbed into a right colon hemi-colectomy as well as a diagnostic lap + small bowel carcinomatosis resection. Um..so what does that mean you ask? Well we have each have a small intestine and a large intestine (also called colon). So the first procedure included the removal of the right (proximal) portions of the large intestine to rid the patient cancer that was localized to that area. We ended up taking a significant amount of the patient's large intestine out, all through only 3-4 tiny incisions into the abdomen. It truly was amazing to take part in such a huge surgery and only leaving behind minimal tracks. The second was similar, but it was localized metastatic cancer of the small bowel. Metastasis is the diffuse spreading of a cancer from one localized area to all over the body. For example, lung cancer can metastasize to the bowel, or the bladder, or the brain. As you can imagine, metastasis is very complex and ultimately is one of the final stages of many cancers. I'd like to encourage everyone (over the age of 50 or earlier if you have family history of colon cancer) to PLEASEEEEE get a colonoscopy every year. Cancer is truly a devastating disease, but the earlier it is detected, the better chance of recovery!

Sorry for the very short and not super descriptive post. My eyes are literally shutting as I type. Yes I know its 9:45 pm, but I have to wake up in 5 hours. BAHHHH.

Oh also, I got to close up a patient today!!! Aka, sutures and everything! More about that later!

Some odd disorders...Part Uno

• Trichotillomania: This falls under the category of impulsive disorders and is characterized by compulsive pulling of hair from one's own body [typically the head, sometimes eyebrows/facial hair/other body hair] that leads to visible hair loss, and could potentially lead to social or functional impairments. The compulsions are worse in times of stress or depressed states.
• Koro: an overwhelming belief that one's external genital (males) or secondary sex organs (nipples in females) is shrinking, retracting and will eventually disappear. Some even believe that this will end up causing his/her death. This disorder is prevalent in Eastern Asia.
• Hallucinogen Persisting Perception disorder: visual hallucinations or flashbacks of the experiences felt during earlier use of hallucinogens in life. This is thought to be a result of reabsorption of the hallucinogen years after last use from lipid stores.
• Dissociative Fugue: sudden, unexpected travel away from home along with the inability to recall parts of one's actual identity and past. This will cause the person to assume a new identity and occupation after reaching this new destination. This disorder usually is seen after a stressful life event.

As I was reading my first aid...I came across these and thought they were the weirdest of them all. Initially I was quite skeptical, thinking that people are just pretending/feigning these symptoms for primary or secondary gain...but after a bit of research, these are actual disorders characterized by the DSM Manual for Mental Disorders. There are a few more I thought were pretty intersting... will tell you more about them later.

Winnie the Pooh - mental illnesses?!?!

Couldn't help but post this (hehehehe):

courtesy of: http://www.g33kpron.com/wp-content/uploads/2011/08/winnie-the-pooh-drugs.jpeg

Dealing with psychotic patients

Two weeks into the psychiatric inpatient service I have been exposed to plenty of psychotic patients. This experience however took the words 'mental' to a whole new level.

A little nervous, and very scared, I slowly made my way to the front desk to announce the name of the patient. "Mr. X, will you please come up to the front desk." His back stooped, Mr. X shows up a few seconds later as I studied his disheveled hair and food stains on his shirt, taking note of his appearance, movement and affect. We make our way to the alcove and I sit down across from his chair. Never had I felt so uncomfortable. But as soon as I received the answer to my first question, all my anxiety and fear drifted away.

"So what brings you in Mr. X," I asked. "Well, I haven't really been sleeping well. You see, ever since my birth, I've had this power given to me to take on the world's problems and make sure that I help people everyday, and not just people from this planet, but the planet I hail from as well as other universes too." Clearly, I would not be doing most of the talking. It didn't stop there. I quickly learned that my patient had been brought to this planet in a spaceship by his real parents to save this earth from all evils in 30,000 B.C., since then he has been carrying the troubles of mankind on his shoulders as he tries to rescue good from bad. His own children had become victims of the devil. Mr. X would hear voices of Jesus Christ telling him to act well and give him power. He had a girlfriend, one from another planet, that came to him to borrow money since he had the ability to create money from nothing. He could speak 26 different languages, his Russian was along the lines of "ahoo hee haa haaa hooo heee haaaa." All this and much more was found out in the first 2 minutes of the interview. This, my friends, is called pressured speech with tangential thoughts. You think you're talkative? Wait till you talk to someone with pressured speech, just get them started on a topic and you can sit there for the next hour waiting to interrupt.

What seemed like minutes, turned into an hour and then more. I began to make sense of the terms that I had read in psychiatry under the schizophrenia section. Schizophrenia falls under psychotic disorders. What is psychosis? Medically, it is defined as a disruption in the perception of reality-and symptoms include: delusions, hallucinations, or disorganized thought. Listed below are brief explanations of each of these symptoms:

• Delusions: illogical beliefs that are held despite evidence of being fake & are inconsistent to a person's background/culture
• Hallucinations: sensory perceptions in the absence of any sort of stimulus
• Disorganized thoughts: thoughts that are disorganized...duh. haha just joking; this will include illogical answers to questions, thought derailment, tangentiality, etc.

So in my patient, he had several bizarre delusions: one of which was that he came from another planet, he was saving the world, his children were victims of the devil. His hallucinations were auditory commands since he claimed to be hearing the voice of Jesus Christ. In addition, his thoughts were disorganized, he constantly jumped from one topic to another (tangentiality) and never really finished his thoughts. This patient also presented grandiosity (unrealistic sense of superiority)--he was able to make money, he spoke 26 languages, etc.

All in all, psych has surprisingly turned out to be very helpful, and I'm so glad to have had this experience. A major lesson I learned, and want to emphasize here, is the importance of one's childhood and the drastic impact it has on the rest of your life. Many of the patients admitted into our service, whether its for depression, psychosis, or bipolar disorder, a recurring theme I've noticed is the lack of stability in their childhood years. This includes anything from having abusive people in one's life [physical or sexual] to not seeing one's parents often because they're always working. One of the docs explained how children that were not held and cradled in the first three months of life are more likely to develop psychiatric problems later down the road...

[reference to be found still...]. So, to all the parents out there, take some time out for your kid, play ball, or even just a daily hug can go so far.

Enough for tonight. Will update on more stuff I see super soon...

past two years...

Take a look at most* (not all) of the notes from the past two years. If combined, they are 44" tall. WHAT?! Thousands of pages crammed into the tiny neurons of my brain...maybe.

Starting a new life...ROTATIONS!

So, you can only imagine how busy second year was judging by the number of posts that I have written..haha. That is about to change! Update in life...I PASSED BOARDSSSSSSSSSS (and am very satisfied with my score), and I've recently started my third year rotations and am loving every (...most) moment of it. I just finished my Neurology rotation, and just started my Psychiatry rotation today. Since I'm a month behind on my documenting, I'm going to try and do a bit of psych and neuro in each post.

I'll start off with my first day at psych since its fresh in my head. I'm currently on inpatient and got to see some super crazy (pun intended hehe) stuff today. But more important than that were the lessons I learned. I'll describe two, of many more to come, real briefly.

First was on countertransference. So what is it, you ask? Medically, its having a preconceived judgement of how a patient is going to act based on people or experiences that you are reminded of while interacting with that patient. For example, Billy bob a new patient that I met with today reminded me of Jackie, a noncompliant patient from years ago, and so my behavior towards Billy bob will be change and I assume that Billy bob will also be noncompliant without actual evidence from Billy bob himself. Believe it or not, countertransference is actually very common in doctors. My attending today emphasized heavily that the act of countertransference is not bad, however, it can easily crossover and become harmful if it goes unrecognized and starts getting in the way of doing your job.

The second lesson I learned was not really a lesson; it was more of an analogy: revenge and forgiveness. Revenge is like going to McDonalds and eating a huge meal that satisfies you only for a few hours. Forgiveness is like eating balanced and healthy meal throughout the day, that will keep you full and satisfied for years to come. Random? Yes, but lets just say it was medically related in that it involved the topic of physical abuse.

Enough of my psych lessons of the day. Lets talk Neurology! First and foremost...I MISS IT SOOO MUCCCHHHHH! I cannot get over how fortunate I was to have started off with such a wonderful rotation with wonderful residents and attendings. I went in with alot of interest because I have loved neurology since undergrad. The nervous system is such a vital part of your body and the fact that it controls every single thing that we do [from blinking to biking] just amazes me!

So, I want to briefly touch on a research topics that I had to look up and present on: Cortical spreading depression. Yeah, I hadn't heard of it either. Its defined as a self-propagating wave of depolarization (activation) of brain cells (neurons and glia) that spreads from the back of our brains (occipital region) towards the cerebral cortices. So...it doesnt seem that bad, right? WRONG. It is actually thought to play an important role in pain and auras of migraines. Pain is a result of the depolarization activating trigeminovascular neurons which in turn induces nociceptors (pain receptors) in the overlying meninges (coverings of our brain). In addition, auras are also thought to be related to cortical spreading depression.

For further information, check out: http://www.springerlink.com/content/q2882h12343u37q8/

That's all folks!