forklift vs legs

Mr O is 45 years old, and had both of his legs run over by a forklift. The first thing I saw of Mr. O were his x-rays.

• His right leg films show an open wound with a fibular fracture (smaller of the 2 lower leg bones); in this case by "open" I mean that the bones is no longer covered by skin or tissue.
• His left leg films reveal open tibial and fibular fractures

Open fractures require urgent operations, so I head to the O.R. to find Mr. O. I will skip to the gory details ( I have pictures on my phone if you really want to see them); but Mr. O woke up with an above the knee amputation on the right, and an external fixation device on the left. The external fixation device allowed us to stabilize his left tibial fracture with screws above and below the fracture line, connected to a metal rod. If you're interested, google "external fixation device" to get an idea of what these things look like. We are hopeful that he will keep his left lower leg, but that remains a question, as he suffered severe soft tissue injuries.

Patients like these are a nice litmus test for someone's interest in orthopedics: if you read this, or saw this and it made your stomach turn...you probably wouldn't enjoy orthopedic surgery. On the other hand, if you really want to see those pictures...

patient encounter - incidental discovery

Mr. S is a 95 year old gentleman who rear-ended another car when he couldn't push the gas pedal far enough to stop the car. He ended up with a pretty good bruise on his right eye, a broken set of glasses, and a broken left hip. He grinned sheepishly and admitted that he probably should not have been driving. The next morning when we ask about his wife, he reports she's "running around town cleaning up all of the mess I made yesterday". He's energetic, optimistic, and is probably the healthiest 95 I've seen.

The trouble is, when we put him through the CT scanner as part of the initial evaluation, we discovered a mass in his pancreas which is likely to be cancerous. What a cruel turn of events. As we enter the room to tell him the news and discuss his options, I find myself wondering....would I want to know?

Mr. S faces the news initially with remarkable practicality. "If your treatment adds 50 years , we don't need to bother because I know I don't have that long to live. But if you can add a few years to my life, that would be something worth pursuing. I honestly love my life"

We return the next day to discuss the situation again, this time with one of our pancreatic experts. At some point, he mentions that Hospice may be an option. "Hospice. Are you familiar with hospice?" the attending asks. Five seconds pass. Slowly. Without answer. Then, "Yes".

Here we are with Mr. S, and in the course of two days he's gone from worrying about his daily errands, to wondering about some potential trouble, to preparing for the end. I wish we didn't have to tell him...

schedule

monthly rotations.

• 2 months orthopedic surgery
• 4 months general surgery
• 2 months of night-float
• 1 month of hepatobiliary
• 1 month of icu
• 2 months of surgery clinic

I am currently on general surgery, and will transition to orthopedic surgery next month

daily schedule (m-f)

• 6 - 7 arrive, print the daily list of patients and review vitals and labs
• 7:00am all residents meet for icu rounds
• 7:30 team rounds begin (and continue really for the rest of the day). we see each patient, make sure to write a note on their chart, and place their orders for the day (diet, medications, lab tests, imaging, etc). discharge patients if ready to go home
• 7:30 surgical cases. we are assigned surgical cases as well throughout the week. i've only been assigned a handful so far (lap chole, gastric sleeve placement, toe amputation)

weekly activities

• m 1-3 skills lab. all interns attend (6 of us) to practice sutures, knot tying, laparoscopic skills
• t 8-10 m&m, grand rounds. review any complicated cases, topical presentations, review journal articles
• f 8-10 basic science lectures

weekends

• 1 golden weekend per month (both days off)
• round beginning at 8, hopefully leave by 2pm

call

• 9-10 calls per month
• day shifts 7a - 7p
• night shifts 7p-7a
• respond to call pager, trauma's, and new surgical patients seen in the er

Trying again

So, I thought I'd give this blog a whirl again. I can't promise that this effort won't meet the same fate as my initial attempt; but I would like to share some of what is going on during my intern year.

I don't know the answer, but I do have some thoughts

There is a certain question that's been haunting me for a while. It's taken many forms: What do you want to be when you grow up? What are you going to major in? What are you going to do when you graduate? What are your goals in the business world? What kind of doctor are you going to be? My answer hasn't really changed...I don't know. The older I get, the weightier the question becomes. As the clock ticks down and I need to make a decision, here are some of my thoughts/options:

• Orthopedics. As I look back on all of the rotations I've completed so far, I've probably enjoyed this rotation this most. I enjoyed the people, I enjoyed the work itself. It fits in naturally with my love of sports. It is the most lucrative of all the specialties I am considering. It also carries some challenges with it. It is the most competitive of all the specialties I am considering, which means I have little to no control over where I would end up for the 5 year residency. I will be so much busier during residency than I've been thus far in medical school. I don't think it's even going to be close. Is it fair to ask Courtney to be move again, and continue to be away from family and friends during such a difficult time? I also think about Kyle and Brynn aging another 5 years without being able to see friends and family more. The bottom line is, we would love to be back in Dallas and that would not be possible with Orthopedics. Another factor is that while I enjoy the work, the lifestyle of a surgeon is the most demanding. I would spend more time at the hospital, be one call more, and miss more t-ball and weekends than for anything else I'm considering
• Internal Medicine. This was the hardest rotation I've taken, but it was challenging in a good way. The internists I worked with matched my notion of what a physician should be: they are supremely knowledgeable, value the physical exam, and excel at communicating with their patients. The residency is 3 years, and there are plenty of opportunities to specialize if I chose to do so. It less competitive, and I have more of an opportunity to control where I take a residency. With my scores, etc; I have at least a decent chance of ending up in Dallas. On the other hand, I am not sure to what extent I was able to picture myself in this field and be excited. I certainly found it interesting, but I'm not sure that I truly enjoyed it. It's difficult to say, though, if I was able to truly gauge the field with my brief look as a medical student
• MBA/MD. UTMB is partnering with a Houston school to offer a MBA/MD program. This would add an additional year to my studies, and I would increase my flexibility. It would certainly be an asset if I chose to open my own practice at any time. It would allow me to go into hospital administration if I became interested in that, and I'd also have the opportunity to be some type of consultant if I chose to do that. I do find that I miss some aspects of business, and this would be a unique opportunity to combine both of my interests. It would also give me another year to sift through my goals in medicine. On the other hand, I do not have any specific goals in mind in pursuing this, and it is difficult to justify dedicating another year, money, etc to something when I'm not sure how I would use it.
• Lifestyle specialties. One of my current fears about Medicine is about being able to strike the appropriate balance with my family life and career life. Most specialties are not forgiving with the amount of time required. Certain specialities offer a very good balance, and very good work hours. Anesthesia and Psychiatry fall into this category. Of the two, I'd say I'm more interested in Psychiatry; but I'm not sure to what extent....

The decision is both overwhelming, and exciting. I'm not sure I'll ever know exactly what I want to be when I grow up, and honestly, I'm not sure I'd want to. I never want to feel like I have all of the answers. I never want to feel like there isn't something else out there. I never want to feel 100% comfortable. For better or worse, I'm trying to do my best. Thanks for your support. Please know that I could never be at my best without you!

5/17 - quick notes

• Today was orientation for Ob-Gyn. I start tomorrow at 5:30am seeing the new moms who just had their babies (post-partum). After that I'll spend a week seeing the moms who are pregnant and are having hospitalized with medical problems prior to their due date (ante-partum). Then I'll have 2 weeks at a gyn clinic, followed by 2 weeks delivering babies (or trying to help).
• Brynn is growing up so fast! She's now eating baby food for dinner every night, and is able to sit up by herself. For a split-second tonight, I mistook her for Kyle because she's so much bigger than she used to be, and she reminded me of him when he was yonger.
• Kyle's is going through another language growth-spurt. He's really starting to put some sentences together. Of course, he also loves to repeat everything he hears...this part is getting really interesting (i.e. choosing our words carefully is becoming more and more important).
• We've started with potty training Kyle. He's doing pretty well: he's really good about a) going when we take him to the bathroom, and b) reporting when he's dirtied his diaper. We'll be excited when he starts to report the need to go!
• Brynn and Kyle will have a new cousin tomorrow....Ellie Chrietzberg is going to make her debut!

4/27 - thoughts, updates

• I wonder how many of the blogs that have been created on blogspot have a post that was created in the past month? 20%? 10%? It's a difficult thing to get in the habit of doing, though I'm still shooting for twice a month.
• My goal of running a marathon may need to be put on hold...my right knee started hurting about a week and a half ago and has not improved with rest.
• We get our initial schedule for 4th year this week. More to come...
• I'm halfway through my psychiatry rotation, and it's going well. I'll be working in a hospital in Houston for the next 3 weeks seeing inpatients (patients who voluntarily sought help with a problem like depression/bipolar disorder or were hospitalized against there will as they were deemed to be a danger to themselves, or others).
• I hope the Mavs can push this playoff series to game 7.
• Hearing "HI DADDY!" from Kyle never gets old, especially when the enthusiasm in his eyes exceeds the enthusiasm in his voice.
• Courtney is a great mom, and I couldn't do it without her: Love you, Courtney!
• Many of the sick patients I see share a number of characteristics: obesity, smoking, hypertension, low socioeconomic status, and chaotic families / home life. Family seems to be particularly important in the development of many of the problems I am seeing in psychiatry. What a blessing to have such a great family! What a shame that there are so many without.