Tuesday, December 22, 2009

CrichothyroDundee


As part of Airway Day, we also go to practice doing cricothyroidotomies (you may know them as tracheotomies, though technically cricothyroidotomies are a subtype of tracheotomies). Trach generally refers to a surgical tracheotomy which take longer and are usually left in longer. In that a surgeon will cut between the Adam's Apple (if you have one) and breastbone, separate the muscles, split the thyroid, and cut through the tough cartilage of the windpipe. In the crich, I swear it felt like all I did was grab a scalpel, feel above, feel below, and oh so delicately jab that sucker in the soft spot of the crichothyroid membrane. (You can also do this with a needle and catheter instead of a scalpel.

We did this on dummies of course. Though I think if I were going into emergency med we'd have to practice on cadavers too. Shudder. The dummies have this jelly-ish plastic "skin" wrap that goes around their necks and velcros together in the back. You can see where other people cut, so you have to keep taking it off and rotating it after someone practices. When it's your turn, you feel for the thyroid cartilage (aka Adam's apple, and yes, even girls have it though it's harder to find), then you feel below for the cricoid cartilage. In between should be a soft spot the width of a finger--that would be the cricothyroid membrane. You can try this on yourself, but for some reason it really freaks me out. I think I'm scared my finger will go all the way through. Then you hold the cricoid cartilage steady, get your scalpel, and make a small vertical incision through the skin and membrane. Some surgical texts teach to cut horizontally then vertically, but the newer thinking is just to cut vertically and be done with it. If you wimp out your first go through, just keep going over it a little deeper until you're in the airway.

Next you have to have a clamp or your finger hold the incision or else it will clamp up. Then hopefully some helpful person will hand you the tube to slip in there and voila, an airway!

Here's a fun part of medical school: It's very easy to forget that step, and nearly all of us did. The first or second guy made the incision, then reached for the tube without holding it. He then looked around and, thinking no one saw him, saw the cut on the neck wrap and slipped his finger back in like he'd had it there the whole time. The kicker is that when I made my cut and forgot to do that, he's the kind of guy who would (and did) yell "OOOOHHH you didn't hold it! You're patient is dead!" I wanted to say "Look here jackass, killing a patient with no one watching is still killing a patient." but he's the type of guy who had already gotten a vanity license plate with "Dr. LastName" on it, and I figured his self-esteem was fragile.


Ok, so we did demonstrate a little on each other.

So that's what you see all the time on TV; someone is choking, has a bee sting, is talking to loudly at a restaurant, and some DIY-er takes a steak knife, straw, ballpoint pen, insert whatever other filthy rigid hollow instrument you want, and saves the guy by jamming it into his throat. Alright, now I'm trained, so I had to ask the question:

"Um, so when would I be able to do this in public without getting arrested or sued?"

Unfortunately for me the answer was, "Well, never really." Dang it. Real indications for it are
  • Major injuries to the face or jaw, such as multiple fractures of the jawbone or severe fractures of the patient's midface. In many cases of facial injury, the airway is blocked by broken teeth or fragments of bone from the jaw and cheekbones.
  • Burns in or around the mouth.
  • A neurological disorder or damage that has caused the patient's teeth to clamp shut.
  • Fractured larynx. Fractures of the larynx most commonly result from automobile or motorcycle accidents, but also occur in cases of strangulation or attempted suicide by hanging.
  • Larynx swollen shut by allergic reaction to bee or wasp venom.

So could I do this? Yeah, I feel completely comfortable with the procedure now. Would I do this? Hmmmmmmm. I'll take that on a case by case basis.

Thursday, December 17, 2009

Intubation Obstacle Course

When I was in New Mexico, the title of this blog was on the schedule for one afternoon. I had no idea what that would entail, but who doesn't love a good obstacle course?

It was more like the obstacles were getting to the patient in adverse but possible situations, not running around in red and blue uniforms hoping you don't have to look for a flag in giant plastic waffles.

It was still fun though.

Number one for me was under an ambulance. Luckily I'm fairly thin and wriggly, so once I maneuvered in the dirt around the hitch, it was no problem. It's actually quite roomy under an ambulance. Not that I recommend getting stuck under there--you never know who's doing the rescuing. Some of the guys had a hard time with that hitch.












Obstacle two was supposed to simulate an unconscious driver who you had to intubate through a windshield. There was no hood of the car simulation to go along with the windshield simulation, so the shorties in our group nearly asphyxiated themselves trying to reach over the wheel. Also, by this time the intubation kit (the yellow thing) had been in the sun for an hour. The laryngoscope could melt your skin.









Obstacle three was a tube meant to recreate a sewer pipe. No sewer part though. It was on a ramp with the dummy's head sloping down into the tube. I rested my own big bucket on the back of the tube to get this one. It actually wasn't that hard except for the spots flashing in front of my eyes after I'd been inverted for a bit. In real life I would have also had my headlamp, but I think a headlamp is pretty much the most useful thing ever invented. I was out at a pig roast with my husband and in-laws a few months ago, and it was getting dark. My hands were occupied with pig and alcohol, and I made a comment that I should have worn my headlamp. My mother-in-law looked at me for a moment and said, "Now that would be embarrassing." We were at a pig roast in the middle of nowhere, wearing matching shirts (reading "Miller's Annual Pig Party" in hot pink), trying not to trip over the tents strewn about the yard for those who overindulged, drinking out of a box of wine in my fold-up chair, listening to a band who got paid in pig, and THAT would have been embarrassing.





Obstacle four was an upside-down dummy strapped to the inside of a bike rack tube. There are two types of laryngoscopes (tubes used to hold all the soft stuff in your mouth up so you can look down the windpipe and put a tube in): Miller and Mactintosh. Miller has a straight blade, Mac has a curved blade. I actually like the Mac much better in this situation; the curved blade made the whole scope shorter, so I could fit it in between myself and the dummy easily.










I really do love to intubate. I have a great story about a "laryngeal tumor" that turned out to be a hot dog chunk in someone's windpipe, but I'm feeling lazy so I'll save that for another time.

Sunday, December 13, 2009

The Interview Trail

Things I've learned so far about interviewing for Radiology.

1. They really ARE the happiest people in the hospital.

2. It's about a 5:1 ratio of dudes to ladies in this process. And two memorable interviews actually had 7 guys and little ole me as the lone estrogen source in the process.

3. Each one of those guys, and all the girls too for that matter, will wear a black or nearly black pantsuit. Two guys even wore the same tie at one interview. I can only remember one person out of 35 who interviewed in a light gray pants suit, and she was going into Internal Medicine anyway.

4. They definitely do not interview in a red dress suit. Guys really can't help this, but ladies? Seriously. Hopefully, the cat is out of the bag that you are of the female persuasion. There is no need to shop in the men's section for interview day.

5. To answer another interviewee's question: If you do not have a black leather binder, you obviously did not get the memo that you would be needing to bring a useless empty piece of cowhide to hold pretentiously and zip and unzip several times throughout the process as if there were anything in there besides your self-esteem. I'm very sorry. If it makes you feel better, I ignored that memo myself. It wouldn't match my dress suit nearly as well as this purse.

6. Bring questions, even if they're not really questions in any sense except your voice goes up at the end. Sure, you feel like a jackass and spend the time they are answering you thinking about where you'd live if you came to that residency, but I am ok with that.

7. Get the residents alone. If a place is terrible, they will let you know. They don't exactly write "Help Me" on their bellies and flash you from behind an attending, but they let you know.

8. I don't know if guys get this, but people ask me what my husband does in the sense of "Will he come here? Because I'm sure you're picking the place purely based on what he wants." I am pretty certain they just assume wives will travel wherever their husbands go, but not so much if their first question (What does your husband do for a living?---not "Does your husband work?") is answered with any type of a real job. I answer the question by saying:

1. We didn't apply to any place we wouldn't want to go. (which is true, and useful)
2. I will make 4 times more money than him after residency is done, so why wouldn't we go where I get the best education? Usually they tilt their head and go, "Well, that's true" as if they haven't ever thought about that argument. I think about it all the time, as I make absolutely no money compared to him right now.

9. That brings me to: Always pretend you want to go to someplace. Are you saying to LIE Al? Weeeellll, I haven't figured this one out. I am pretty terrible at hiding my feelings (I am also terrible at talking about them according to my hubby--apparently I just stomp around with an angry face.) but am fantastic at lying truthfully. So, when one less than awesome program put the thumbscrews to me to say I wanted to go there, instead of giving a straight, "Yes", it came out like, "Well, I really like this and that about here, and my family is close, my husband could go to law school...this will definitely be one of our top choices." Notice I didn't say "top". It could be a top 20 choice. Always leave wiggle room; you never know how the other interviews are going to go.

10. Write thank-you cards after you're done. I don't know if anyone reads them, and my handwriting is like a fourth-grade serial killer's, but I think you should write them anyway.

11. Rank the programs as you go, but each interview so far has changed my mind. I will absolutely think I want to go one place after one interview, then I go to another one that doesn't look as good on paper and it blows me away. We're just going to sit down after they're all done and have a nice dinner to talk about it.

Monday, December 7, 2009

Da Boards

One of the crappiest parts of becoming a doctor is the constant testing we have to undergo. No, not pyschiatric testing, though you could certainly make a good argument for it. (Here's a little gem from med school Orientation Week: "By the end of these four years, 1 in 4 of you will be medicated for depression, and that's only the ones we catch."--our dean of students)

We take something called the United States Medical Licensing Exam-USMLE for short, "The Boards" for shorter. You don't take it all at once, where would the fun be in that? Nope, it gets dragged out in three expensive steps, four really because Step 2 has two exams, plus your specialty-specific boards.

Step 1 I took back before I had a blog. I was not a pleasant person around that time. Step 1 basically tells you if you can be a plastic surgeon or not, in varying degrees of "Not." I thought I wanted to be something far less competitive at the time, so I took it a week after our regular final exams and then went to Montana and got engaged. I think I chose well. That's not to say I didn't spend nearly every waking hour from the end of February to May 21 studying. I ate, slept, and breathed medicine. Literally. I studied while I ate (as the pancake syrup on my review book shows), I listened to board review podcasts while I exercised and in the car, and more than a few nights I would study in my sleep. I had actually memorized pages of my First Aid for the USMLE review book and would re-read them page-by-page in my dreams. I always woke up really pissed off when that happened; it was supposed to be my 7 hours of freedom from studying.

Anyway, that went well enough to make me competitive for radiology (though more on that when I blog about interviews), and I got a nice 15-month break before I had to take the next step.

It's a lot harder to study when you live in the same house as your favorite person in the world. During Step 1, we didn't live in the same city, so I could obsessively study without distraction. Step 2 was a bit harder, luckily I did well enough on Step 1 that no one asks about Step 2.

What really blows about Step 2 is that there are two costly parts: the multiple-choice Clinical Knowledge exam ($400 I think), and the real-life-ish practical Prove-You-Speak-English-and-Are-Not-A-Total-F$%^wit, excuse me, Clinical Skills Exam(which costs you $1,000 for the privilege of taking). Ouch. Plus, since CS involves 12 actors pretending to have various vague symptoms in a simulated clinical experience that is both timed and taped, you have to go to one of a very few places in the country to take it. In the midwest, you have Chicago or Houston. I think there are five total locations across the US. Every IMG (international medical graduate) as well as every graduating US medical student has to take this exam. In one of five spots. With a maximum capacity of 24-48 people a day, no weekends, no holidays, I don't feel like they even do Mondays or Fridays. I paid in February to take the exam, and I got a spot in November. Tell me how awesome this system is.

That part I did two weeks ago. My mommy and I drove up and stayed with relatives. We had a case review book and practiced scenarios. I'm not sure if it prepared me for taking the boards, but it was a good time. My mother likes to go off-script, for example:

Mom as Patient X: Doc, I'm also worried that this might be AIDS
Me as Dr. Z: Why do you ask that? Is there a reason you are concerned about AIDS?
Mom as PX: Well why do you think? I sleep with everything that walks! I probably do drugs too!
Me: Mom, I don't think that's in the case book.
Mom: So? You know that's what's going on!

That exam lasted from 3pm to 10pm. The testing center served us dinner (other testee: "I always wondered what a $1,000 dinner would taste like. I thought there would be more meat.") and told us we could talk to each other, as long as we didn't talk about anything related to the tests under penalty of death. Did I mention we were sitting in our assigned seats, which were set up classroom style so we were each facing the back of the person in front of us? Not very conducive to chatting, I helpfully pointed out to the proctor. Plus no one felt like talking at the beginning when we were dreading the next 8 hours and no one felt like talking during the exam because the life was being sucked out of us. The worse part was that the actors, I mean "patients", had a role to play, and they focused so hard on that role that you couldn't get them to talk like real people. The only thing I'm good at in clinical settings is to get people to open up by laughing or talking about themselves. These people were two script lines deep, and they were too busy concentrating on if I asked the right questions or not to relax and laugh. Blech.

Sometime in your first year of residency, you take Step 3, another multiple-choice exam. I heard this is the easiest of all three, though I was told Step 2 was easier than I thought it was. All I know is I had better take it quickly before I lose all semblance of clinical knowledge in my chosen specialty.

Thursday, December 3, 2009

Everybody's a Comedian

Just when you thought I couldn't fit anymore fun into a single night in the ER, I had one last bit of awesome before I left.

By this time of night the resident had grown to trust me (something about watching me get puked on with nary a curse word while still holding suction and prepping the intubation kit endeared me to him I suppose). So he said I could come help perform a paracentesis on the alcoholic in room 44 if I liked. Uh, YEAH! (Uptight attending: I don't think this is something for someone on her level; she shouldn't do that, humph harrumph. Resident: Oh, she'll only assist me *wink wink).

In a paracentesis, we stick a big hollow needle in someone's ascites (fluid)-filled belly and drain it out using either suction on the wall or vacuum cannisters. It looks like warm lager, which is why I drink brown ales.

So I go in to check out the victim and wowza he looks like he's eight months pregnant (I wouldn't say nine because his belly button hadn't popped out quite). "Is all this fluid because of my drinking doc?" he asks after I'd introduced myself. "Uh, YEAH. Most likely. Unless you also have hepatitis from IV drugs." I'm kidding. I didn't say that. Even if you're sure that's what did it, even if you've warned the patient for years that whatever nasty habit they had would do it, there's some sort of weird doctor's code stating you have to hem and haw a little bit and offer some other, less their-fault explanations. I think it's because doctors don't like to see people cry. Or because the patient might try to sue them if they don't tell them their lung cancer could be from the environment and not just the 30 years they've smoked (which, of course it could, just like the quarters under your pillow could have been left by the tooth fairy and not a creepy neighbor with a spare key). People are dodgy when it comes to accepting responsibility for their poor health decisions.

Anyway, he asked the question a few more times for good measure, and I was tickled to see the resident answer in the same way I did. The guy felt like talking I guess, because then we talked bout all the other things the cirrhosis did to him.

For starters, with your liver kaput, certain jobs it used to take on don't get done, such as breaking down estrogen. This man did not care for his new moobs. Also, blood doesn't flow through it as well as it used to, leading to huge veins popping out of your skin around your belly button (called caput medusae because your liver is kaput and it looks like medusa's hair. I made that first part up.) You also don't break down cortisol as well, which gives you all sorts of fun: thin skin, buffalo hump between your shoulder blades, skinny little arms and central obesity on top of your ascites.

As we talked about this, he decided to show me each characteristic. Thank goodness he didn't know it could also make your testicles shrink. My favorite comment of the encounter: "Look! My arms used to be as big as YOUR arms, now they're sticks!" Yes, he was talking to me. About my arms. The (male) resident made him repeat what he said and then had a good chuckle.

I am not some burly Amazon. I'm not even the tallest one in my family, though that would be hard with a 6-ft. sister (Sorry, it's the truth Sis). I just seem to inspire these kinds of comments in people. Especially the elderly and alcoholics. Those and comments about my purty teeth. Which I prefer, thank you very much.

Tuesday, December 1, 2009

The Second Time I Soiled My Pants

Neither of these times was my fault, by the way.

After I'd watched the orthopod massage bones back in place, I had no time to change my now-bloody pants (I was cursing the packing wisdom that told me to leave my plug ugly, wipe-clean ER shoes in Kansas because I'd only wear them once, but at least someone had put booties on me) before we had another guest in the trauma bay.

I swear no one listens to the EMS people when they come give report. Then they are gone and you don't know why the patient is semi-comatose with a tube down his throat and nothing to knock his gag reflex out.

I had actually heard bits and pieces of what they'd found out from his mom (apparently you can't give a good history if you yourself are lights out). He was 20 and had overdosed on "some pills". I don't know if it was intentional or not, but that isn't really our concern anyway. "Get the intubation kit ready for me" the resident said. Holy crap, something I actually knew how to do! I'd spent the last two afternoons intubating dummies (actual dummies, not just idiots) so I was ready, standing right beside the resident at the head of the bed, when the patient started blowing chunks. Son of a....

I thought I'd had an ugly night with LifeGuard. This guy's was worse. The problem with and LMA (laryngeal mask airway) is that they do not seal off the trachea to protect from gastric contents. They are actually not supposed to be used if the risk of aspirating is anything more than minimal. And as I mentioned before, this patient was not all the way out, so he still had a gag reflex. Though he may have been vomiting from something he ingested, any one of us would be hurling if someone stuck that tube down our throats without knocking us out.

Maybe he was unconscious when they first got there. I don't know why they chose an LMA vs. a tube. But now the question do we put him under and put a real tube in, or just suction and keep the airway that was working in. His O2 sat was actually pretty good, in the mid-90's for now. The resident and attending disagreed on what to do, meanwhile I was standing in vomitus trying to dodge each fresh assault while still keeping my torso and hands where I was told to. I accidentally forgot to mouth breathe once and thought I was going to add to the fray.

The attending won out, and we left the LMA in. When the chest X-ray came back, he had crap in his lungs. I personally agreed with the resident, who was pretty mad that we probably made the guy's situation worse by a. making him vomit and b. allowing him to aspirate it. Suction can't get everything coming up; I'm sure some slipped around that LMA. So he probably has pneumonia now, or chemical pneumonitis on top of his OD and whatever problems led to it in the first place. Awesome.

In situations like that you have to bow to the attending. It's a judgement call as to what treatment approach you take, and in the end he's the judge.

After he'd finally stopped throwing up and was on his way to ICU, I went to the locker room to find new pants. Damn it. A scrubs PYXUS. If you've never dealt with this, it is basically a vending machine that takes a code instead of money. I had neither. Usually used for medications so that no one gets handsy with the controlled substances (at least without being recorded as having taken them out), some frugal hospitals also put them in the locker rooms to retain scrubs from disappearing. This one also exchanged dirty scrubs for new scrubs, however since I was wearing scrubs I pilfered from my own institution, I couldn't exactly do that either.

My only option left was to hang around the ER, stinking the place up and looking pathetic until someone took pity on me and loaned me a pair of pants. Which happened thank goodness. Luckily I'd worn real pants to work that day, so I didn't have to change back into grossness after the shift.