Fun day in the OR

I "saved" this post from last Thurdsday, my last day of OB, and I was going to elaborate on the interesting stuff I saw and participated in on my last day...but unfortunately I'm stacked on time, so instead you get some pics below...and explanations of the cases/surgeries to come later.

Monochorionic (one placenta) diamniotic (two amniotic sacs) twins with twin-to-twin transfer syndrome delivered by C-section:
basically the one baby is hogging all the blood and nutrients from the other, so to ensure that both their survival they were delivered earlier

Cervical spine; not apparent from this picture representation, but our patient had two herniated intervertebral discs (the light blue between the vertebrae above) C5-6 and C6-7 levels leading to compression of some of his nerves

To relieve the pressure on the nerves from intervertebral disc compression, the intervertebral disc is removed the space is filled in with an allograft (bone from a cadavar; usually bone from the hip bone)

Finally it is stabilized with a metal plate anteriorly

Here is what it can look like on MRI; the arrow is pointed at the herniated disc. The "gray" between the two "white" lines is the spinal cord; the "white" lines on each side represents the spinal fluid and should be continuous, but you can see above that the disc bulges into the fluid and impinges on the cord

Pictorial example of what a herniated disc can look like

The last case I scrubbed on was a laminectomy of two lumbar levels. In this case, the neuropathy (nerve problem) was due to a narrowing spinal canal (where the spinal cord runs). To relieve the pressure off the spinal cord, a decompression is done through a laminectomy; basically, a window is cut from the back of the vertebrae to air out the cord and give it room

That's all I have for now. I started my orthopedic surgery rotation on Friday, and I've been pretty busy since. The hours suck....not used to getting up at 4:00, but luckily my roomate has to get up the same time, and he doesn't get home until 8:00 or 9:00 at night. The remainder of my immediate schedule consists of being on call this weekend, flying to Philadelphia for a test next Wed through Sunday, and starting up my 2nd from last MBA class.

C-Sections....and Slooooooooooooooowness

Holy crap...I'm dyin here...miraculously, somehow my blog and even myspace for some reason today got through the hospital computer internet block, don't know how, but works for me cause I am bored. First the good news, sort of...I got an interview invitation at an Orthopedic Program in OH. It's in a city called Massilon, which is between Columbus and Clevelend. I haven't set up a date yet, but the crummy part is that I just came from OH last week, so now I have to fly back out and spend some more money I don't have. Oh well...I'm hoping to put the interview off for a little bit if possible, in case I get another one out there in OH, so I don't have to make several trips. But overall, I'm stoked, cause it means at least I have a chance somewhere.

In other news...last night before I left we had a C-section delivery for a breech presentation. I was waiting on her all day to deliver...but the baby just would not progress any further, so the physician grabbed me to help him for a C-section. A good thing about not having this be a planned C-section...well not for the patient...but for me...was that I got to be first-assist. Normally all of the OB/GYN physicians work in tandem, leaving the student...that would be me...doing little but retracting the bladder...and staying out of the way. With such short notice, the physicians aren't able to have their partners come and help, so they are left with the low man on the totem pole...the lowly student. The C-section went successfully, I was a little worried at first, because it took some time for the baby to move around and cry, and actually looked a little lifeless for several seconds after the delivery, but it wasn't too long, before it started flopping around and crying. Strange enough...this morning we had only onoe delivery scheduled. The patient was to come in the morning and we were to give her some Pitocin to induce labor. Unfortunately, this baby was in breech presentation also, so again, she was brought to the OR for a C-section, and again...I got first dibbs to assist. But since that C-section...ohhh...at 8:00 this morning, I've done nothing but study ortho stuff. I've been confined to my "office" trying to study, and now I just want to peel out my eyeballs. Some genius thought that for this rotation the students should stay until 7 every day, even if nothing is going on, just in case, something miraculously shows up.

Anyways, I guess I should explain a little aobut breech presentation. Presentation for labor simply specifies what part of the baby is headed out first. Normal presentation is with the head presenting first, also known as vertex presentation. In addition normal is also with the occiput (back of the head) facing anterior.

When the baby presents butt first, it is considered a breech presentation, making it much more difficult to be delivered vaginally. Breech presentations occur in 2-4% of pregnancies. There are variations to the breech presentation, but the baby we had yesterday was a complete breech, and the one this morning a frank breech, with its feet up by its ears.



There's your damn education for the day.

Almost game time

So I made it back from Ohio in one piece...it was definitely not a vacation... in an effort to impress or be seen as much as I could, I had to sacrifice any sleep or opportunity to explore the city and surrounding areas. I did get a good glimpse of the program, and I can tell that they are very strong didactically and they see a ton of cases. The first full day I spent, was in the OR from 7am until 9pm, watching 12 or so cases. The second day was pretty much the same in terms of how busy they were. The last day I was there was spent in clinic to see the other aspect of the program. I was amazed at the efficiency of the physician and his staff. In 8hrs, he saw a little over 70 patients, but none of his exams seemed rushed. He was a very good physician, had good repor, explained everything to his patients, including x-rays and the results of their operations and was able to do an inclusive musculoskeletal exam all within several minutes. At the same time he was able to ask me questions and do some teaching along the way. Overall it was a good trip, as far as really getting a chance to know people, it was difficult. With 15residents and 7 orthopedic surgeons, and only three days, I did my best to meet them all, and then I concentrated on just a handful to spend more time with and hopefully they will remember me. The bad news is, that statistically, the chances aren't that great. Last year they had 75 applications...12 interviews...all for 3 slots. So...I'm hopeful, but as always, I'm going to spread my seed everywhere (that wasn't meant to sound bad...but it just does) and apply to 20+ programs. An alternative if I don't get in this year, is to do a rotating internship year and then apply to the 7 orthopedic programs that only take intern applications.

Thursday, I had to get back into the grind of things with OB. Of course, the first day back was extremely busy. I assisted with a C-section and 3 vaginal deliveries. Friday was much slower with only a few GYN surgeries, and Labor and Delivery was slow upstairs in the hospital, so I decided to lounge around the OR, and try to see some other cases. Luckily, I was able to scrub in on an odontoid fracture (part of the C2 vertebrae of the spine, shown below) with a neurosurgeon. He was very good at teaching me stuff and letting me do a lot also. Having met me only once, he still let me do some cutting, cauterizing, and then left me to close up the incision. The case was interesting and rather rare. He stated that he gets one of these cases maybe in a year or two. Most of these cases happen in situations with great trauma...in this case it was a very elderly man, that slipped and fell in church.

The fracture that the patient had was the type II fracture, which is the most common. This is a view of the anterior surface of the C2 vertebrae as if you are looking straight at someone who is facing you. The C1 vertebrae sits on top of the C2, and because it is shaped as a ring, it pivots on the odontoid of C2 (the pointy thing that looks like a head and neck). With a fracture through the base of the odontoid, there will be a lot of instability between the two vertebrae. To fix the problem, a screw was drilled from the left base of the C2 body through the head of the odontoid that had fractured off. It was a neat case to see, and since I have two days left and he has surgeries on Wed-Fri, I'm hoping to scrub a few more spine surgeries.

The weekend was pretty lame, I mainly studied. I start my string of orthopedic surgery rotations on Friday for the next three months, so I've been trying to review a lot of stuff, so I can look somewhat smart. I'm a little nervous...but I know it's game time...and if I want to get into any of these programs...I'm going to need to work my @$$ off.

I do have a roomate now for the remainder of the month, which is kind of nice. Dan, one of my classmates (who went to school at West Valley with Uhlman/Peaches/Steele/etc) is doing urology here in town, so he moved in with me to Salwa's apartment...so it was good to have someone to rattle of the days details with.

That is all for now...I will try for one blog a week...mainly on weekends...that is my new goal...

Destination unknown.....ruby ruby ruby soho.....

Yeahhhhhhhhh....I made it to Ohio... so far another state uncharted by the Dang. These next couple days should be interesting, hopefully I'll have time to explore the best of what Ohio has to offer. Well...I Just got in, picked up my pimp @$$ rental car the Chevy Cobalt (Sure as hell doesn't beat the El Camino that Sarah took me to the airport in today)...and now i've sorta settled into Jake and Kirin's condo in Columbus. I will have more details on this "trip" later when I get back to Kansas City on Wednesday (Maybe earlier if I get some extra time this week), but it's getting late and I have to be at the hospital in Dayton by 6:00 tommorrow...so I think this calls for bedtime.

Enough already

Well, it's been two weeks...and I'm pretty much tired of the whole baby/vagina/uterus stuff. Sorry...after a few vaginal deliveries/C-sections/hysterectomies...I'm pretty much done. The actual procedures itself aren't that bad. In fact, the days down in the operating room (OR) go by quite fast, it does get old...but it's the closest I've been to an OR in a few months, and it can be quite refreshing. The deliveries on the other hand suck, because there is so much sitting around and waiting. I've tried to master the art of predicting the time in which the babies will deliver...but that doesn't always work as planned. The things I look at on the monitors, is how much the cervix has dilated (full dilation is at 10cm) and the station; station refers to the position of the presenting part of the baby (head/arm/etc, whatever is coming out first) in relation to an anatomical imaginary line in the female pelvis. The OB nurses usually go in every hour or so to check these two parameters by doing a manual exam and then they document it in the computer. Supposedly, the approximate rate is 1cm of dilation per hour, but that never really happens. For instance, two days ago, I sat in my "office" and was lounging around, because the patient was only dilated to 4cm; 20minutes later, the little bastard popped out, and I missed it all....I probably should have gotten an idea that something was happening when the stampeding herd of nurses ran by...but I thought...nah...couldn't be...she couldn't have dilated that quickly....boy was I wrong. To contrast that, on the same day, I went into the delivery suite when a patient was dilated to 10cm and ended up standing there for over an hour before the baby finally came out. It took forever because the woman had a small vagina and the baby's head was huge...it rivals Shaefer's dome. Then for one last example, today when I got to the hospital at 6am, one patient was dilated to 2cm, by the time I left at 7pm she was only up to 6cm....so you just never know.

I did come up with a small theory I've been discussing with the other student that is with me. He was commenting on several of the nurses and how, outside the hospital we would never really find them attractive, but somehow on the "inside" we do. Strange?!?! Well, my theory is that we develop "hospital goggles," similar to the familiar "beer goggles" that everyone is aware of, but instead of the opposite sex looking better with an increasing number of alcoholic goodness, the level of attractiveness is instead directly proportional to the number of hours stuck in the hospital...ie. 13hr work days...makes the 34wk pregnant nurse...slightly appealing....I know, I know....just ridiculous...and the 6-8cups of coffee really doesn't help either. Anyways...enough of that.

Lastly, I just wanted to make a comment about all the stuff happening about the terrorists and their plots that has been all over the news today. I am amazed at how long it has taken people to start accepting the reality of our times and how many more acts like these or attempts that we will probably see in our lifetime. Sadly, this is the fear that many overseas have lived with daily for decades...it just that we have been blinded to it all. As successful as today was in thwarting the plot...it still doesn't make me feel safe. It won't take long, before the security gets lax again...and people start to forget. I'm not sure if the purpose today was at all to simply cause mass destruction...or if it was just to continue causing disorder in all our lives...if that is the case, then they have surely succeeded.

Oww

My arm hurts...I forgot to mention yesterday that I got a tetanus shot too for the hell of it. You should get one every 10 years and most people were required to get it at the age of 15 during HS. I wasn't sure when I received the shot last, so I got it anyways. If any of you remember what the shot feels like afterwords...you'll probably remember that it is like a charliehorse that never goes away. I am annoyed...my L shoulder is throbbing.

So...aside from that, I started my first day of OB/GYN today. It wasn't too bad, today was mostly an introduction day, and things were really slow in Labor and Delivery. I will be in Labor and Delivery again tommorrow and then after that, me and the other student will alternate between that and GYN surgeries in the operating room. We had one whole delivery today, and it happened really quickly. During our orientation, we heard someone yelling about a delivery. I ran into the delivery suite looked at the woman on the table, and saw her pushing and screaming. Not much of the baby could be seen at this point, and the nurse told me to glove and gown up. It probably was less than another minute for me to gown up and then glove up, but when I looked up, the baby was already in the doctors hand's. Normally for first pregnancies, moms will push for at least 1 to 2 hours, somehow, this woman did it in less than a few minutes. Aside from being suprisingly quick, it was also suprisingly clean. I have heard so many horror stories about deliveries with amniotic fluid, blood and feces flowing everywhere...luckily my first experience was not that. It's amazing to see the process of bringing the baby into this world, and I can see how people would enjoy this as a profession. Unfortunately...I could never see myself doing this.

The hospital and rooms themselves are very impressive. The suites are basically modeled after hotel rooms, and creates a very relaxing atmosphere for the patients.

Besides the delivery for the day, the rest of the day was spent studying. We are required to be at the hospital every day (minus weekends...thank god) from 6am to 7pm. If there is nothing going on, we have to be studying, or at least appear to be, because the doctor comes by to make sure we are doing something and not skipping out early. Hopefully the rotation will pick up, because busy rotations go by much quicker.

Now I have a whole two hours to finish my paper on Germany's healthcare system. But before then...I have to get on a little soapbox about the paper. Many of you already known how our healthcare system is composed and how we pay for our care; we basically purchase insurance to cover the majority of costs, and for those that can't afford it, the elderly and/or the disabled, are covered by medicaid and medicare. In Germany, the government requires every employed individual under a certain threshold ($40,000) to enroll in their health insurance program. Over 90% of the country is enrolled in these programs. The pool of funds that runs this program is attained through 50% contributions from employee paychecks and the other 50% from their employers. In the past it has been touted to be one of the better healthcare systems in the world. The United States has always been ranked lower and is consistently being compared to Germany as well as other countries' health care systems. The problem is, these other systems don't work either. Countries like Canada and the UK have a lack of access due to socialized medicine; sure everyone receives care, but can the provider system really handle it off of what they get reimbursed for? In Germany, they're system is actually heading towards one similar to ours. Years of neglecting cost containment have led them to have the same problems we face.

What is the underlying problem leading to these costs? Is there a solution? I think that the problem of increasing health costs is a product of our own doing. Major factors of rising healthcare costs are increased utilization of services and the advent of new technologies and pharmaceuticals. Here is the problem: these new technologies and pharmaceuticals have worked to prolong our lives; prolonged lives leads to more people with inevitable chronic conditions, thus they need to use more services. It is a vicous circle...we work to increase quality...but the increased quality leads to increased costs...where does it end?

Any ideas for heathcare improvement in the US?

Holy hell...hope that rambling made any sense.

*3 in a row....get some