Tuesday, June 24, 2008
Thursday, June 12, 2008
Emergency
After my April rotation in surgery, I spent the month of May working in the emergency room. The following are short stories of my month in the emergency room. Unfortunately, I don´t have any pictures, but I think the stories will make up for it.
Motorcycle Accident (May 7th)
In my first 10 minutes in the emergency room, I assisted a doctor as he stitched up the forehead of a 18 year old male who had hit a pole while riding his motorcycle. He had a hole in his forehead the size of a half-dollar all the way to the bone and a irregular line ran from his forehead to the back of his head. After numbing him with lidocaine, the doctor began the hour long process of suturing his head back together. Near the end he let me do a stitch. As I pushed the needle through the skin, I guided the needle between the skin and the cranium. It was great to get the experience, but my excitement was muted by this patient´s prospect of living with a nasty scar the rest of his life.
All in One Day (May 13th)
When I arrived in the emergency room this morning a lady was screaming. I thought it was temporary, but she kept screaming for the next hour. It set the tone for the rest of the day.
Around 9 AM, a 55 year-old-man entered the emergency room on a stretcher after arriving in an ambulance. After taking x-rays of his head and chest, we learned that he had a fractured cranium, fractured clavicle, and 3 fractured ribs. When initial observations were done, an intern and I had to insert a urinary catheter. He showed me the process and let me do it. However, after getting the catheter half-way in, we realized that the catheter was too large, due to the man´s enlarged prostate, which had narrowed the urethra. The problem was later fixed with a smaller catheter.
As I was leaving the room of the man, another doctor called me over to hold the head of an 80-year-old woman who was in a car accident with her daughter. The lady was moving her head and was complicating the doctor´s attempt to stitch her right ear. After 3 minutes, she had stopped moving and began drooling. The doctor realized there was a problem when the daughter tried talking to her mom and there was no answer. The woman was quickly moved to the room with life-support and immediately intubated. According to the doctor, the woman had a brain aneurysm and was now in a coma. A day later, I saw the patient´s daughter crying outside of the hospital. I never found out if the patient came out of the coma, but reflecting back on what happened that day, it´s frightening to think that a blood vessel was rupturing inches from my fingers, an event that might have killed her. It reminded me that everything that happens here is permanent and the consequences can be severe.
The Patient and the Finger (May 15th)
Despite seeing several suturing done nearly every day here at the hospital, I had not had the opportunity to serve a patient completely by myself. Today that changed. A 35-year-old man entered with a 8 cm cut along his finger. After filling the syringe with lidocaine, I injected it in the crevices of the cut. For simple cuts like this one, this part is typically the hardest, as the patient usually registers the pain. Also, while the risk is low, injection of lidocaine into an artery can be fatal. In order to avoid this, we pull on the syringe before injecting. If the syringe fills with blood, the point of the needle is an artery and needs to be repositioned. In the end, I made 4 sutures. While the cut of this patient was very innoxius, it was great practice and this level of contact with the patient.
Electrocardiograms (May 21th)
Over the last few weeks I´ve been doing several electrocardiograms per day. While I began accompanying the other doctor´s, they now let me do them by myself. Today, I had my first solo electrocardiogram with a woman. As we need to put 6 electrodes across the chest of the patient, it was very uncomfortable to be serving a patient in an exposed state. However, by the 5th or 6th woman, I had adjusted. It is one of the realities of the job all doctor´s must adjust to eventually.
The Good with the Bad (May 25th)
Near the end of my shift today, an elderly man arrived by ambulance in the emergency room. After finishing with a another patient, I went to his room to observe the doctors. The first thing I noticed was blood all over the floor near his bed, where he had vomited just moments before I arrived. Despite the vomiting, the doctors had gotten him an IV of a glucose/water solution and intubated him, and were working on placing a catheter to his heart. With a yellow tint to his skin, it was clear something had either gone with his liver or kidneys. The doctor told me that he had cirrhosis of his liver; however, since he was talking, it seemed like the doctor´s had things under control. After the catheter was successively placed, I left the room to help with another patient. An hour later, I heard crying from the room and looked over to see the man laying in his room without any of the machines that had been supporting him and his daughter crying by his side. He had died. It was almost surreal. Two hours earlier he was talking and now he was gone. Maybe it was because I did not know the man personally or maybe I´ve become desensitized to death, but I was not bothered by this man´s death. While I felt bad for the family, it´s part of the job when you´re working with the sick. I just hope I don´t become too distant from the patient to see feel for the grieving family.
Scorpion Bite (May 27th)
Probably the most common single reason for emergency room visits here in Morelia are scorpion bites. While they often cause temporary discomfort in the majority of the patients, some can be fatal. During my first few weeks I observed several bites and the treatment process. The doctors taught me symptoms for the 3 levels of severity of scorpion bites. The first begins with weakness and ranges to asphyxiation in the 3rd level, due to the swelling of the throat. The standard treatment is an injection of an anti-venom enzyme that breaks down the poison of the scorpion. Typically, 30 - 60 minutes after the injection, the patient walks out cured. During my last week in the emergency room, the doctor let me give the injection. While it was not hard, it was another opportunity to get first-hand experience with the patient.
Motorcycle Accident (May 7th)
In my first 10 minutes in the emergency room, I assisted a doctor as he stitched up the forehead of a 18 year old male who had hit a pole while riding his motorcycle. He had a hole in his forehead the size of a half-dollar all the way to the bone and a irregular line ran from his forehead to the back of his head. After numbing him with lidocaine, the doctor began the hour long process of suturing his head back together. Near the end he let me do a stitch. As I pushed the needle through the skin, I guided the needle between the skin and the cranium. It was great to get the experience, but my excitement was muted by this patient´s prospect of living with a nasty scar the rest of his life.
All in One Day (May 13th)
When I arrived in the emergency room this morning a lady was screaming. I thought it was temporary, but she kept screaming for the next hour. It set the tone for the rest of the day.
Around 9 AM, a 55 year-old-man entered the emergency room on a stretcher after arriving in an ambulance. After taking x-rays of his head and chest, we learned that he had a fractured cranium, fractured clavicle, and 3 fractured ribs. When initial observations were done, an intern and I had to insert a urinary catheter. He showed me the process and let me do it. However, after getting the catheter half-way in, we realized that the catheter was too large, due to the man´s enlarged prostate, which had narrowed the urethra. The problem was later fixed with a smaller catheter.
As I was leaving the room of the man, another doctor called me over to hold the head of an 80-year-old woman who was in a car accident with her daughter. The lady was moving her head and was complicating the doctor´s attempt to stitch her right ear. After 3 minutes, she had stopped moving and began drooling. The doctor realized there was a problem when the daughter tried talking to her mom and there was no answer. The woman was quickly moved to the room with life-support and immediately intubated. According to the doctor, the woman had a brain aneurysm and was now in a coma. A day later, I saw the patient´s daughter crying outside of the hospital. I never found out if the patient came out of the coma, but reflecting back on what happened that day, it´s frightening to think that a blood vessel was rupturing inches from my fingers, an event that might have killed her. It reminded me that everything that happens here is permanent and the consequences can be severe.
The Patient and the Finger (May 15th)
Despite seeing several suturing done nearly every day here at the hospital, I had not had the opportunity to serve a patient completely by myself. Today that changed. A 35-year-old man entered with a 8 cm cut along his finger. After filling the syringe with lidocaine, I injected it in the crevices of the cut. For simple cuts like this one, this part is typically the hardest, as the patient usually registers the pain. Also, while the risk is low, injection of lidocaine into an artery can be fatal. In order to avoid this, we pull on the syringe before injecting. If the syringe fills with blood, the point of the needle is an artery and needs to be repositioned. In the end, I made 4 sutures. While the cut of this patient was very innoxius, it was great practice and this level of contact with the patient.
Electrocardiograms (May 21th)
Over the last few weeks I´ve been doing several electrocardiograms per day. While I began accompanying the other doctor´s, they now let me do them by myself. Today, I had my first solo electrocardiogram with a woman. As we need to put 6 electrodes across the chest of the patient, it was very uncomfortable to be serving a patient in an exposed state. However, by the 5th or 6th woman, I had adjusted. It is one of the realities of the job all doctor´s must adjust to eventually.
The Good with the Bad (May 25th)
Near the end of my shift today, an elderly man arrived by ambulance in the emergency room. After finishing with a another patient, I went to his room to observe the doctors. The first thing I noticed was blood all over the floor near his bed, where he had vomited just moments before I arrived. Despite the vomiting, the doctors had gotten him an IV of a glucose/water solution and intubated him, and were working on placing a catheter to his heart. With a yellow tint to his skin, it was clear something had either gone with his liver or kidneys. The doctor told me that he had cirrhosis of his liver; however, since he was talking, it seemed like the doctor´s had things under control. After the catheter was successively placed, I left the room to help with another patient. An hour later, I heard crying from the room and looked over to see the man laying in his room without any of the machines that had been supporting him and his daughter crying by his side. He had died. It was almost surreal. Two hours earlier he was talking and now he was gone. Maybe it was because I did not know the man personally or maybe I´ve become desensitized to death, but I was not bothered by this man´s death. While I felt bad for the family, it´s part of the job when you´re working with the sick. I just hope I don´t become too distant from the patient to see feel for the grieving family.
Scorpion Bite (May 27th)
Probably the most common single reason for emergency room visits here in Morelia are scorpion bites. While they often cause temporary discomfort in the majority of the patients, some can be fatal. During my first few weeks I observed several bites and the treatment process. The doctors taught me symptoms for the 3 levels of severity of scorpion bites. The first begins with weakness and ranges to asphyxiation in the 3rd level, due to the swelling of the throat. The standard treatment is an injection of an anti-venom enzyme that breaks down the poison of the scorpion. Typically, 30 - 60 minutes after the injection, the patient walks out cured. During my last week in the emergency room, the doctor let me give the injection. While it was not hard, it was another opportunity to get first-hand experience with the patient.
Tuesday, June 3, 2008
The Volcanoe/Ruins
In 1943, a volcanoe erupted and buried a town at its base. The only building left standing was the town´s church, which is now covered in 20 - 30 feet of lava rock. As we walked from the town to the ruins of the church, we got glimpses of the churches one remaining tower. When we arrived, I was struck the amount of rock that now covered the church. Between the 30 feet of lava rock that now buried the church and missing church steeple, the force of the eruption was very clear. All in all, it was great to get out of Morelia and see some of the diversity of Mexico´s rural scenery and culture.
Video (1 of 2)
http://youtube.com/watch?v=ISj9X-EY8Gc
Video (2 of 2)
http://youtube.com/watch?v=ISj9X-EY8Gc
Monday, June 2, 2008
Uruapan National Park
Last weekend I left Morelia to go to Uruapan National Park. The park is supplied by a natural spring near the entrance. As we travelled through the park there were another beautiful waterfalls draped by beautiful tropical foilage. While we did not see much wildlife, there were these gorgeous white butterflies. Near the end, there was a clavadista diving from a tree. It was very Mexican. All in all, the walk took about an hour.
Despite enjoying the park, I left the park a little unimpressed. I think we are spoiled by beautiful scenery in the Northwest and the park here seemed almost like an imitation of what we have in the Northwest. I´m so used to our parks, being largely untouched by man and left in it´s completely natural state. However, the National Park at Uruapan had man-made waterfalls beside the scenery. It felt like they were trying to compensate for the nature. It was still beautiful, and I enjoyed the time there, it just made me appreciate more the beauty of the Northwest.
Check out two videos of the Park. The first is at the base of a waterfall. The other is of a clavadista diving from a tree. Enjoy!
Video (1 of 2)
http://youtube.com/watch?v=3eMUKXcUVt4Video (2 of 2)
http://youtube.com/watch?v=yZdG97WuHbsSaturday, May 17, 2008
Another Tumor...
The day after the kidney transplant, I scrubbed in to my second surgery with Doctor Garcia. The patient was a middle aged man with a tumor the size of a volleyball on his right inner arm. During the course of the surgery, the doctor showed me different important nerves and arteries of the upper arm as he cut away the diseased tissue from the normal tissue.
The first nerve we reached was the ulnar nerve. After watching several surgeries, I was always amazed that the doctors were able to identify the nerves from connective tissue, because the look so similar. When I asked the doctor how he was able to do it, he explained that the cauterizer they use to cut through tissue will illicit a electrical impulse along the nerve and cause a muscle contraction. After this happens, the surgeon knows they are in a region with a nerve.
An hour later and after much more cutting, we reached the brachial artery. It is often crucial that they find arteries before cutting in order to avoid excessive bleeding. The doctor explained to me that they can identify arteries because they actually move with the beat of the heart. In the case of this patient, the artery was in a fairly tough to reach area as it ran through the middle of the tumor. After they had successfully removed the brachial artery from the tumor, the doctor actually showed me the phenomenon of the artery moving with the beat of the heart.
In the final stage of the surgery, the surgeon uncovered the median nerve of the upper arm. The tumor was finally completely removed after 3 hours of sugery. Before the surgery ended, the gaping hole left by the tumor had to be closed. In a surgery like this, some care must be taken in making a cut to allow enough skin. At the beginning of the surgery when the surgeon initially cut, I noticed that he didn´t cut an area as large as I had expected. In the end of the surgery, there was barely enough skin to cover the huge hole left by the tumor. The preservation of the skin is a component that´s crucial to the surgery, but something that never occurred to me until this surgery.
This surgery was incredibly interesting because I got to see and touch the intricate parts of the body in a live patient. I don´t anticipate having this kind of experience again until the thrid or fourth years of medical school.
This surgery was incredibly interesting because I got to see and touch the intricate parts of the body in a live patient. I don´t anticipate having this kind of experience again until the thrid or fourth years of medical school.
Thursday, May 8, 2008
Fútbol
I have been to two Monarch soccer games during my time here. Soccer to Mexicans is what the NFL is to Americans. The fans are passionate and hate seeing their team lose. The stadium reminded me of Reser, but only a lot older.
Throughout the game, venders sell a number of items from beer to noise makers. A popular snack during the game is garbanzo beans with salsa and limes. They sell them unpealed, so you have to removed the shell in your mouth like sunflower seeds. I thought I would give them a try. Needless to say, it can become very messy.
The first game I saw was with my host dad and his two sons. The game was a tie at 0 - 0. The second game I went with some friends. Unfortunately, Morelia let San Lois score in the first 2 minutes, and the game ended on a 1-2 loss for the Monarchs. Overall, I love sports, but watching the fans and being in the culture of the stadium was equally as fun.
Tuesday, April 29, 2008
Kidney Transplant
While the surgeons do many technical operations here, this one might be the most spectacular. It requires two teams of 4 surgeons and 2 different rooms. And, as an observer of the surgery, I had the privilege of watching each part and moving room to room.
The surgery began in the room with the nephrectomy of the donor. It was a very clean surgery, taking only 30 or 40 minutes. I had been so accustomed to surgeries where large tumors were removed after traversing 3 inches of fat. This was nothing like that. Simultaneously, in the room next door, the surgeons removed the diseased kidney from the recipient and were preparing the site for the transplant. When both rooms were ready, the kidney was removed. According to the doctor, the kidney can go a little over an hour without oxygen before the risk of failure begins to climb. The clock was ticking... First, the kidney treated with an electrolytic solution called Bretschneider solution. After about 15 minutes of treatment, the kidney was moved to the other room and placed in the recipient. First, the surgeons attached the renal vein and followed with the renal artery. Without a blood supply, the kidney had turned almost white. The moment all the blood vessels had been reattached, the doctors released the clamp on the renal artery and vein, and the kidney quickly turned a dark red. It was the moment of truth for the surgeon. It told them that everything was connected right. The surgery finished up with the connection of the ureter, which delivers urine from the kidneys to the bladder. Despite being only one vessel, this part actually took almost an hour. Since the ureter, like the blood vessel, must be hollow to function properly, it took a lot of precision. All in all, the surgery took about 4 hours.
Nephrectomy on donor (part 2).
Kidney in electrolytic solution being prepared for the transfer to recipient.
The kidney being moved to the recipient from the solution.
The surgeons connect the connective tissue to the new kidney.
After the clamps were released on the blood vessels, the kidney fills with blood and turns the healthy red. It was the moment of truth for the surgeons.
The surgeons are preparing the ureter on the kidney to be connected to the ureter of the recipient.
The surgery began in the room with the nephrectomy of the donor. It was a very clean surgery, taking only 30 or 40 minutes. I had been so accustomed to surgeries where large tumors were removed after traversing 3 inches of fat. This was nothing like that. Simultaneously, in the room next door, the surgeons removed the diseased kidney from the recipient and were preparing the site for the transplant. When both rooms were ready, the kidney was removed. According to the doctor, the kidney can go a little over an hour without oxygen before the risk of failure begins to climb. The clock was ticking... First, the kidney treated with an electrolytic solution called Bretschneider solution. After about 15 minutes of treatment, the kidney was moved to the other room and placed in the recipient. First, the surgeons attached the renal vein and followed with the renal artery. Without a blood supply, the kidney had turned almost white. The moment all the blood vessels had been reattached, the doctors released the clamp on the renal artery and vein, and the kidney quickly turned a dark red. It was the moment of truth for the surgeon. It told them that everything was connected right. The surgery finished up with the connection of the ureter, which delivers urine from the kidneys to the bladder. Despite being only one vessel, this part actually took almost an hour. Since the ureter, like the blood vessel, must be hollow to function properly, it took a lot of precision. All in all, the surgery took about 4 hours.
X-ray of the ureters of the donor.
Nephrectomy on donor.
Nephrectomy on donor (part 2).
Kidney in electrolytic solution being prepared for the transfer to recipient.
The kidney being moved to the recipient from the solution.
The surgeons connect the connective tissue to the new kidney.
After the clamps were released on the blood vessels, the kidney fills with blood and turns the healthy red. It was the moment of truth for the surgeons.
The surgeons are preparing the ureter on the kidney to be connected to the ureter of the recipient.
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