Medical School 2020, Year 4, Week 28 (Advanced Surgery, week 2)

Still with the cadavers… this week we focus on neck procedures. Budding neurosurgeon Bri will focus on the anterior approach to a cervical fusion (called an ACDF, anterior cervical discectomy and fusion), while the rest of us focus on the technique for a tracheostomy (“trach”) and thyroidectomy. Bri passes out expired tracheostomy kits including a percutaneous (“perc”) trach kit.

Our trauma surgeon professor describes the scene: “It is an eerie night on call. At 2:00 am, an airway alert is sent out. It’s only you there. You arrive in a crowded room with a blue patient and the anesthesiologist puts the laryngoscope in for the third time. He isn’t able to intubate. The patient’s heart rate is dropping.” She pauses.  “The patient is about to code. He needs an airway. What do you do?” With blank stares, she gives us the answer: “Well first, you need God on your side so pray the patient is not obese. After that, all you need is an endotracheal tube and a scalpel.”

“Everyone palpate landmarks on each other. Feel the cricoid cartilage.” (The horizontal prominence below the Adam’s apple.) Our professor explains that there are multiple paths forward. “You have to choose one. Know what you are most comfortable with performing.” There are three main options: a cricothyroidotomy (tube inserted into the larynx through the cricothyroid membrane); an open tracheostomy (cut down on the trachea to insert a tube); a percutaneous tracheostomy (tube inserted into the trachea through a needle stick with serial dilations). “A cricothyroidotomy is a temporary procedure. It will need to be revised to a tracheostomy to prevent damage to the larynx over weeks, but in this scenario nothing matters if the patient can’t oxygenate.” She continues, “Old surgeons trained in an age of open trachs. Most trainees are more comfortable performing perc trachs.”  

We head to the anatomy lab to practice performing a tracheostomy with the expired kits. “My advice when you arrive at your new hospital is grab a kit for each procedure and open it up. An experienced surgeon will struggle performing a procedure if there is a new kit.”

For the next three days, we focus on the technical aspects of a thyroidectomy. The general surgery residents join us for this. The fourth and fifth year residents help walk the interns and medical students through removing one lobe of the thyroid. “Stay as close as you can to the thyroid when you divide blood vessels.” A third year chimes in, “Thyroids scare me. One small misstep and you’ll hit the recurrent laryngeal nerve.”

We finish the rotation at a coffee shop that is a five-minute walk from the anatomy lab. The trauma surgeon recounts her experience on a civilian medical response team, which was deployed after Hurricane Katrina in New Orleans and following the 2010 earthquake in Haiti. “Contrary to popular belief, a vast majority of the patients we treat are not injured from the disaster. Instead, we care for typical medical emergencies, for example, heart attacks, wound infections, appendicitis, and preterm labor, in a suddenly austere environment,” she explains. “In Haiti, a single generator powered the makeshift intensive care unit and operating room. Of course this went down for about 24 hours. Our team bagged a preterm intubated baby when the ventilator backup power stopped. She survived!”

Bri comments that his sister is in the Army Reserves as a nurse. She was recently mobilized, but the entire unit is staying in a hotel waiting for orders. This does not surprise the trauma surgeon. “Yeah, my team was sent to Iowa for two weeks waiting for orders only to be sent home eventually without having done anything.”

Statistics for the week… Study: 0 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Burgers and beers with Lanky Luke and Sarcastic Samantha. Samantha deliberates on the pros and cons of switching jobs. She is exhausted from stringing along patients who need consults with specialists who hide in hopes that someone on the next shift will take the patient instead. “I looked at the academic hospital, but they pay $30,000 less.” Luke: “I strongly recommend against a pay cut.”

The rest of the book:

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Medical School 2020, Year 4, Week 27 (Advanced Surgery, week 1)

I am excited to start a surgical elective with my favorite retired trauma surgeon who led our first-year anatomy lab. Jane, Buff Bri, Southern Steve, Lanky Luke,, and myself each choose various surgical techniques to work on for the next two weeks. We have three untouched cadavers to work on. 

We meet at a local coffee shop that is walking distance from the anatomy lab. Jane and I bring our new puppy for socialization! The trauma surgeon spends the initial 30 minutes giving us puppy advice from her experience training service animals. We each identify various surgical techniques to focus on. Jane, Luke, Steve and myself will use our time with the cadavers to focus on abdominal exposures and neck dissection. Bri, applying to neurosurgery, will perform an external ventricular drain (EVD) and various craniectomies for aneurysm exposures.

The next day, we meet at 9:00 am in the anatomy lab. We focus on placement of thoracostomy tubes (“chest tubes”). Our professor describes the triangle of safety bordered by the latissimus dorsi, pectoralis major, and the imaginary horizontal nipple line. We pair up. I extend the cadaver’s arm to open up the rib spaces. It’s no small feat due to the rigidity of the joints. Jane makes a small incision and then uses Metzenbaum (“Metz”) scissors to dissect down through the subcutaneous fat and through the intercostal muscles. “The surest way to get kicked out of the OR is to use Metz to cut suture. Metz are incredibly expensive and ruined by cutting suture.” Jane then takes a Kelly clamp and tries to push through the last centimeter of muscle and pleural lining. “Heave!” exclaims the trauma surgeon. “Push harder!” With an audible pop, Jane shoves the instrument into the pleural cavity. “Good! It’s a lot more force than you realize.” She then does a finger sweep. “I feel the lung!” She then smoothly places the chest tube. “Some people will say to orient the chest tube towards the apex for a pneumothorax and towards the base for an effusion. The apex always works.” 

My turn. Jane holds the arm up while I make an incision. “You’re really digging deep!” the trauma surgeon comments. “You have just made the most common mistake of interns and ED docs. Don’t tunnel up along the chest wall to the axilla; go straight to the ribs.” Once I pop into the pleural cavity, I struggle to advance the chest tube, unable to push through the resistance. The trauma surgeon takes a feel sweeping her finger in the cavity. “Wow, feel all the adhesions. This patient must have had a bad pneumonia causing all this scarring of the lung to the pleura.” She adds, “This is how you really hurt a patient. If you just blindly shove the tube in, you can tear the lung causing bleeding or a bronchopleural fistula [connection between lung airway and outside]. Always, always feel for adhesions with the finger thoracostomy before you insert the tube.”

Thursday morning we meet at a local coffee shop to discuss rectal bleeding and peptic ulcer disease. The nearby coffee drinkers must have loved our discussion on the significance of the “sweet smelling black loose melena” versus “red-streaked formed stool”. Trauma surgeon: “Blood is a spectacular cathartic.” Bri: “If a patient is bleeding out, they are shitting out.” The trauma surgeon chuckles, “Exactly.”

Statistics for the week… Study: 2 hours. Jane and I watch a section of Acland’s Video Atlas of Human Anatomy over wine to prepare for next week. Sleep: 7 hours/night; Fun: 2 nights. Example fun: weekend AirBNB with Jane’s family, including a 6-month-old nephew. There would be less depression and anxiety in this country if everyone held an infant once a year.

[Editor: It might be best to hold someone else’s infant. “Parenthood and Happiness: a Review of Folk Theories Versus Empirical Evidence” (Hansen 2012; Social Indicators Research) says “people tend to believe that parenthood is central to a meaningful and fulfilling life, and that the lives of childless people are emptier, less rewarding, and lonelier, than the lives of parents. Most cross-sectional and longitudinal evidence suggest, however, that people are better off without having children. It is mainly children living at home that interfere with well-being…”]

The rest of the book:

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Medical School 2020, Year 4, Week 12-24 (Interview Trail)

After a long hiatus due to my laziness and the author being a resident, here’s an addition to Medical School 2020… It’s the fall of 2019. SARS-CoV-2 is just beginning to build mindshare in Asia. Our hero is looking for a job…

Three months off for interviews, each of which is progressively less exciting.

There are three classes of surgery programs: academic, community, and hybrid. Academic programs typically require at least two years of research in addition to the 5 PGY (post graduate) years. Our hospital’s residents warn that academic programs struggle to deliver case volumes for training. Residents may participate in complex robotic whipples, but won’t learn bread and butter procedures. The best opportunities are grabbed by fellows, who don’t exist in community programs. Many academic programs ship residents off to satellite community hospitals with higher case volumes that enable better training for going into general practice.

My first interview is at a community program in a comfortable suburb of a Northeast city. After checking into the Best Western, I walk around the main street for an hour before I head back to change into business casual attire for the evening reception at a local bar. Three other likely applicants are waiting in the lobby for the 6:30 pm shuttle.

An applicant from a Southwestern DO school explains that he doesn’t know much about the program or the area. “Beggars can’t be choosers. I’m just happy to get an interview.” An applicant from a prestigious medical school is less grateful. “I don’t expect to go to a place like this,” she says, “I’m using it for practice.”

Several residents and their families are enjoying beer and finger food. A couple of attendings, including the program director, are chatting with applicants about hobbies. At 8:00 pm, the attendings leave to allow the residents to speak more candidly. “One important factor that I wish I had considered in applying for surgery residency is the level of trauma exposure,” explains a PGY4 (rising chief). “We are not a level 1 trauma center. We stabilize traumas en route to the main city trauma center. We get our sexy GSWs [gun shot wounds] in our fourth year rotation at the trauma center.” There are advantages: “You don’t get as many trauma cases, but you don’t have to spend half of your time being an amateur social worker.”

I wake up at 5:00 am for an early morning walk to the hospital for 6:00 am remarks over catered Chick-fil-A. The program director, a soft-spoken, humble 60-year-old MIS (minimally invasive surgery) surgeon, introduces himself and describes the unique opportunities at the program. One that appealed to me is the chief service. “We are proud to still offer a chief service. Three months of the year you will rotate on the chief service where you run the ship. You interview patients in clinic, and schedule them for surgery. You do the surgery. You manage their complications. You see them at their post-op visit. We also teach you about the intricacies of billing. There is an attending available for any issues, but this is your service.” He added, “This used to be commonplace at surgery residencies but has fallen out due to insurance issues and case volumes. The administration and I are confident enough in our residents to continue this opportunity.”

(What is not stressed is that the chief duties are mostly restricted to Medicaid patients. Care of the privately insured is overseen by more senior physicians.)

We had four 30-minute interviews with selected faculty. I interview with a young vascular surgeon who moved here because the cost of housing near her NYC fellowship was beyond her means. Most of my interview with the chair focused on his love of poker. I tried to steer our conversion back to medicine by alluding to the similarities between surgical decisions and the risk analysis with poker. “If you come here, we’ll have to invite you to our poker nights.” In my interview with the program director I ask him what he is most proud of. “I am proud that I would let any graduate of this program operate on my family.”

After the morning interviews, we have a Panera-catered lunch with residents popping in and out between cases. One interviewee is from a Seattle-based medical school, “My home residency program ships their 4th year out to Chicago for 2 months,” she said over our Panera-catered lunch. “They get 10 GSWs a day and hit their numbers in a few weeks.” The program director provides some concluding remarks. “I know this is early on in the interview process. Each of you is qualified and has an exciting surgical career ahead of you. Most of you will not come here, and that is okay. We would love to have you.” He continues, “I would like to leave you with two final thoughts: First, take a deep breath, you will match. Every applicant we interview is competitive and will match. Second, get excited. You have chosen an amazing path. You will play such an important role in the lives of others. The best surgeons are humble because they understand that we stand on the shoulders of giants whose achievements have allowed our patients to trust us. Honor this pact and safe travels.”

Those who don’t have to get on a plane immediately are invited on a 45-minute tour of the hospital, which is as close as an interviewee gets to patients or an operating room. I found these fascinating and always took the opportunity to join.

(Mostly because of a lack of interest in the geographical location, I did not rank this program highly in the Match and therefore I never learned how high they ranked me.)

Lanky Luke interviewed at a new Accreditation Council for Graduate Medical Education-accredited residency program started last year by a previously successful program director who had moved to a beachside hospital. The night before the interview the interns and residents got together at an upscale restaurant featuring an open bar. “The attendings were drunker than the interns! Everyone was hung over for the interview the next day, which thankfully didn’t start until 9:00 am.” Luke loved it. “Basically you just work with the attendings day in and out. The interns operate like crazy.” Our surgery chair, however, discouraged Luke from giving this program a high rank because it would be more difficult to get a job than if he went through a more established program.

Jane returns from boot camp and two back-to-back away rotations at military hospitals. After three months she has missed a lot of our class drama. I am also not up to date on the newest gossip. To mend this, we get lunch with Ambitious Al. Jane asks about Southern Steve. “Is he still with that ICU nurse?” Al laughs, “No, he’s been dating an M2, and they are getting engaged tonight.” He adds, “Y’all should come to the afterparty tonight!” Jane asks after our classmate who had suffered a stroke at age 10 and had some trouble with one hand and his gait (see Year 1, Week 31). Al responds, “He doesnt go here anymore.” (He dropped out during the third year.)

[Editor: If his stroke symptoms prove to be mentally debilitating he can serve as a U.S. Senator from Pennsylvania.]

A few residency programs ask for a supplemental application, typically a two-page application with four questions. Examples: How would you deal with conflict of opinion between providers in the care of your patients? How would you approach one of your fellow residents not carrying his or her share of the workload? Oregon Health & Science University: “We value diversity in its many forms and strive to create an inclusive community.  Please let us know how you will both contribute to and learn from our community during your training at our program.  (250 words or less)”. Perhaps due to my failure to minor in Intersectionality as an undergraduate, I was not selected for an interview by OHSU.

The main drama and stress of this period is trying to match in the same city as Jane. She’s restricted to military hospitals and I’m restricted by being a white male with an above-average, but not top-one-percent score on Step 1 and 2. Neither of us can write our own tickets.

The rest of the book:

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UC Davis applies UC Davis research to create unsuccessful physicians

Econ nerds at University of California, Davis did a huge study across hundreds of years of history and came to the conclusion that success was heritable, just as intelligence and conscientiousness tend to be genetically determined (see “The heritability of conscientiousness facets and their relationship to IQ and academic achievement”). I summarized this research in the following blog posts:

How is UC Davis applying its own research? “With End of Affirmative Action, a Push for a New Tool: Adversity Scores” (New York Times, July 2):

The scale rates every applicant from zero to 99, taking into account their life circumstances, such as family income and parental education. Admissions decisions are based on that score, combined with the usual portfolio of grades, test scores, recommendations, essays and interviews.

In other words, if your parents were unsuccessful, UC Davis wants you as a medical student!

The NYT article actually confirms the UC Davis economists’ conclusions:

There is also a family dynamic. Children of doctors are 24 times more likely to become doctors than their peers, according to the American Medical Association. It’s hard to know why the profession passes down from generation to generation, but the statistic drove the association to adopt a policy opposing legacy preferences in admissions.

The tendencies to enjoy sitting in biology lectures, studying for tests, and slicing up cadavers are “passed down from generation to generation” but the Followers of Science at the New York Times can’t come up with an explanatory mechanism.

Separately, let’s have a look at UC Davis’s most famous recent pre-med major, Carlos Dominguez. KCRA:

Dominguez came to the U.S. near Galveston, Texas in 2009 from El Salvador.

A U.S. and Immigration and Customs Enforcement official confirmed to KCRA 3 that ICE has placed a detainer with the Yolo County Sheriff’s Office, which means the agency would take custody of Dominguez should he be released from local custody.

Detainers are requests to state or local law enforcement agencies to remove non-citizens arrested for criminal activity once they have been released from their custody.

The ICE official referred to Dominguez as Carlos Alejandro Reales-Dominguez and said his immigration case had been closed in April 2012. He had come to the U.S. as an unaccompanied minor from El Salvador in 2009 near Galveston, Texas, and was transferred to a family member at the time.

Mr. Dominguez thus will qualify for preferential admission to UC Davis Medical School due to the adversities of (1) being an undocumented immigrant, and (2) having an encounter with our racist criminal justice system.

The good news for folks who actually live in Davis, California, is that their health is guaranteed to be excellent because the town is rich in (“essential”) marijuana:

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Medical School 2020, Year 4, Week 11 (Nephrology Week 2)

Nephrology is all about vascular access. How do you get a device that can draw out enough blood flow for the dialysis machine? A patient who has a temporary need for dialysis, e.g., from septic shock leading to poor kidney perfusion, will get a “VasCath”, a large bore central venous catheter in the internal jugular vein. This will get patients through a few weeks, but if they need longer term dialysis they will need to get a tunneled catheter. The tunneled dialysis catheter (TDC) has fewer infection complications than a free-standing Vascath. If a patient will be on long-term dialysis, a discussion about an AV fistula versus graft (synthetic tube) is made with a vascular surgeon or interventional nephrologist.

I head to the outpatient center and start with vascular access procedures. I watch as the interventional nephrologist performs balloon angioplasty and stenting for narrowed fistulas. For the third one, is my turn to do the procedure: I cannulate the graft with the needle, I insert the guidewire, dilator, and finally the balloon gadget. We then take fluoroscopy images (contrast injected dye with live X-ray video) to identify where the stenotic regions are. There are two narrowings, one near the graft insertion into the vein and a “central” stenosis on the left subclavian vein. The attending explains he had a central line, and that is a common cause of central stenosis. We balloon up both of them and take post contrast. Immediately it looks better, and you can even feel the “thrill” (vibration from the flow) increase. Very satisfying!

After three cases, I join an older Iranian nephrologist and head to the dialysis unit. There are about ten quiet patients with glazed eyes in chairs. They’re not watching TV or reading books. The only sound is white noise from the dialysis machine’s spinning roller pump. “Welcome to Purgatory,” my attending whispers. “We keep these patients alive, but a vast majority live a miserable life with amputations, heart failure, on oxygen, wheelchair-bound or, worse, SNF [skilled nursing facility; pronounced “Sniff”] dependent. This is Hell on Heart.” 

We interview a 68-year-old black wheelchair-bound male with a right-sided above-knee amputation. He has been on dialysis for 3 years and was recently hospitalized for COPD and CHF exacerbation. He was discharged from a 3-week stay in a nursing facility back to his home. The nephrologist asks, “What do you notice about everyone here?” I respond, “This looks and smells like death.”

We then relax in his office for two hours. “Nephrology is one of the least competitive fields, with fewer applicants than slots. I always tell my [internal medicine] residents to apply for a nephrology fellowship,” he says. “We’re some of the higher paid specialists, right up there with cardiology and gastroenterology because we do procedures. Nephrology is the gatekeeper to dialysis. ESRD requiring dialysis is the only condition that I know of that will get you a one-way ticket, no questions asked, to disability.”

[Editor: Medicare spent $51 billion on ESRD in 2019, which does not include SSDI payments.]

Nephrologists make most of their money by managing dialysis patients, even though this takes less time compared to hospital consults and clinic visits with atypical kidney failure patients (e.g., Lupus, rare auto-immune diseases, obstruction from BPH).

“Dialysis costs Medicare about $60,000 per year, but the government spends more on covering inpatient hospitalizations,” said the nephrologist. “The average is roughly $120,000 per patient per year. In the pre-Medicare age, these patients would have died years earlier, but now Medicare pays for all the cardiovascular complications [heart attacks, leg ischemia, strokes] in these sick patients in addition to the vascular access complications [infections and stenosis]. Over the years they have bundled the payments so we get a fixed monthly fee for dialysis patients and take a hit if they get hospitalized for a vascular access complication. We perform outpatient procedures [e.g., stents and balloon angioplasty] to ensure they don’t wind up in the hospital. Two interventions per year is typical.”

My attending explains the economic landscape for nephrologists. Each dialysis patient yields roughly $250 per month to the physician and requires weekly face-to-face evaluations, normally done during a dialysis session, either by the doctor or a nurse-practitioner. The maximum practical roster is 500 patients, yielding gross income of $1.5 million per year, but this requires quitting the hospital job and sharing some of the money with the ACP. “Ninety percent of our time is spent with consults at the hospital, procedures, or office visits, but all our money is from dialysis patients.” The nurse-practitioner or physician’s assistant is critical to hitting the 500-patient goal. The NP handles three out of every four required dialysis patient evaluations. Quite a few nephrology groups also get revenue via owning the dialysis center itself and therefore obtain profits from the separate Medicare reimbursements for machine operation.

[Editor: Davita is an example of a corporate dialysis center owner. The company enjoyed a market capitalization of roughly $6 billion in January 2020.]

As we are packing up to head home, the nephrologist is paged for a STAT consult. We head to the hospital surgical ICU. The 57-year-old female with breast cancer on chemotherapy presented to the ED for acute onset abdominal pain. She was found to have Acute Diverticulitis – an uncontained hole in the sigmoid colon. She lives in a rural area without surgical capabilities. Due to weather conditions, they had to transport her via a 1.5-hour ambulance ride. When she arrived at our hospital, she was in extremis. She underwent emergent exploratory laparotomy with suctioning of 3 liters of liquid stool in her peritoneal cavity and resection of the perforated colon segment. She is too unstable so the surgeons performed “Damage Control” and left the bowel in discontinuity and placed a temporary abdominal closure device. She is in septic shock, intubated on high ventilation support (34 breaths per minute), and getting multiple vasopressors to keep her brain perfused and heart pumping. Her kidneys have failed. She will die without immediate dialysis. We get consent from the devastated family for renal replacement therapy. This is not the three-hour sessions three times per week (intermittent hemodialysis or “iHD”). Continuous renal replacement therapy (CRRT) is the life-prolonging intervention that continuously filters toxins in patients who are too unstable to handle the high flow rates required for iHD. We place the CRRT orders and the critical care nurse begins to hook up the machine as the critical care team places a VasCath. As we walk out of the hospital, my attending comments, “If her sepsis response does not peak in the next 12 hours, this is futile.” (The family decides to withdraw care after 72 hours of ICU care. Her small bowel became necrotic from the high doses of vasopressors. I am there when we turn off the CRRT machine and return her blood, pull the endotracheal tube, and stop the vasopressors medications. Her family is at the bedside when her heart stops 10 minutes later.”)

Friday: the attending walks me through a full fistula exam. There are a lot of techniques to evaluate the fistula. This has become a lost art due to widespread access to ultrasound. First, I listen with my stethoscope. “A good fistula should have a continuous rumbling sound that does not vary with the heart beat. If you begin to have a high pitch blowing whoosh of the fistula with systole, it means it is beginning to narrow,” he explains. “Remember these AV fistulas are massive blood vessels right next to the skin. The most common reason for stenosis [narrowing] is from poor cannulation by the dialysis nurse. If you traumatize the vessel too much, it will lead to aneurysm formation. This will form a clot and over time cause narrowing of the vessel. The most feared complication is ulceration. Just last week I had a consult from a patient (not ours) whose fistula ruptured from an ulceration while she was showering. EMS described a murder scene as she was bleeding out. Her husband was smart and put a finger on the clot proximal to the bleeding. She lived and made it to the hospital but these can be scary things.”

My attending points out that close to 90 percent of the dialysis patients are black, despite the fact that we serve a region that is only about 20 percent African American. This is due to higher rates of uncontrolled diabetes and hypertension. NIH says “African Americans are almost four times as likely as Whites to develop kidney failure.” A black American who lives to age 75 is a likely candidate for kidney problems.

We also talk about his perspective on cardiovascular disease. “Let me ask you something. Why has no study shown stenting a patient with coronary artery disease has any benefit, either mortality or quality of life after six months?” the attending asks. “Because although you can open up the artery, the stent will narrow almost immediately. In a coronary stent, it’s hard to access to blow it back up. That’s why AV fistulas work. We can go in every few months and blow it back up.”

Statistics for the week… Study: 3 hours. Sleep: 8 hours/night; Fun: 1 night. Med School Prom. Students and faculty dress up for a night of hors d’oeuvres and 2-drink tickets at a local restaurant venue.

The rest of the book:

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Medical School 2020, Year 4 Week 10 (Nephrology elective)

Picking up with our medical school diary, authored by our anonymous mole inside the system… It’s the fall of 2019.

I meet at 9:00 am in the hospital dialysis unit with nurse practitioner (NP) Nora. She’s 34 and has worked at the nephrology practice for four years, progressively taking on more responsibility. She is my contact during the two-week nephrology rotation. The attending, a 42-year-old interventional nephrologist, is on call at the hospital and performs procedures at the nearby clinic. NP Nora and I hold down the fort.

We run the list of patients in the hospital who will need dialysis today, and go over the consults from overnight and this morning. Consults come in three flavors: 

  1. The most common consult is for patients with end-stage renal disease (ESRD) who are admitted to the hospital for an unrelated reason, such as a GI bleed, myocardial infarction, or pneumonia, and need their dialysis while in the hospital. We try to continue their standard schedule, e.g., “TTS” for Tuesday, Thursday, and Saturday, about two hours on the machine per session at an outpatient dialysis center. Five clicks in Epic and the dialysis nurses will know what to do. 
  2. Acute renal failure. These patients are typically unstable, e.g., from septic or cardiogenic shock that resulted in such poor perfusion to the kidneys that they shut down. These patients have electrolyte derangements and toxin buildup that is not being filtered by the kidneys. They need either intermittent hemodialysis (IHD) or CRRT (continuous renal replacement therapy; “slow” dialysis). 
  3. The last type of consult is for electrolyte abnormalities, frequently low or high sodium. These are usually “tea and cracker” old ladies who do not eat enough, alcoholics, and the occasional ultra distance runner. If the sodium is corrected too fast, the osmolarity change can result in brain damage. (A University of Virginia fraternity contributed the highest recorded sodium to the medical literature: “Survival of acute hypernatremia due to massive soy sauce ingestion” (Carlberg, et al. 2013).)

We get six consults throughout the day, four of which are for ESRD admits. I watch Nora’s exam on the first ESRD consult. She examines the patient’s vascular access, an arteriovenous (AV) fistula, and determines his schedule and typical net volume change from the outside records. We get these on paper because the patient’s dialysis center’s electronic medical record does not interface with our Epic system. It takes 20 minutes to find the needles we’re looking for in the haystack of paper. We evaluate his volume status by listening to the lungs and checking for peripheral edema in the legs. I do everything on the next ESRD admit, with NP Nora watching and helping.

An AV fistula is a surgically-created connection between a large vein and artery in the arm that is brought close to the skin for cannulation with a needle. This fistula is allowed to mature until there is adequate blood flow for dialysis, while ensuring adequate perfusion to the distal limb. 

In the afternoon, we get a consult for acute renal failure in a 42-year-old uncontrolled type 2 diabetic patient who presented yesterday evening in septic shock from a necrotizing soft tissue infection of the leg. He probably stepped on a sharp object and did not notice the wound for a few days. He underwent a below the knee (BTK) amputation of the right leg, and was sent to the ICU. His kidneys have not recovered, and they are starting him on CRRT because his blood pressure drops too much with the two-hour iHD.

The most interesting consult during the week is on a 58-year-old patient with metastatic bladder cancer. The prognosis is that he is likely to live only one or two additional months. The cancer has obstructed both ureters, resulting in progressively worsening kidney failure. The tumor responded to first-line therapy, but recurred three months later, and did not respond to second-line therapy. The patient presented to the emergency room with left flank pain from hydronephrosis, a kidney ballooning from distal obstruction. He underwent placement of a nephrostomy tube (a catheter that the interventional radiologist pokes into the kidney to drain urine) to drain the kidney and prevent further deterioration of his last remaining functional kidney. We explain that we could start dialysis on him, but would need to coordinate with the oncologist given a palliative approach may be a better path for him. He will likely have end stage renal disease within a few weeks.

The oncologist agrees that palliative is the best option given that the patient has only about a 10 percent chance of some response from rescue or “salvage” chemotherapy. This will entail three months of debilitating pain (at a cost of over $100,000 to Medicaid). The oncologist did not sugar coat matters for the patient: “This is probably the worst case of bladder cancer I have ever seen. If you don’t go on dialysis, the way you will die is you’ll become very tired. You’ll have periods where you are lucid, and then you will go back to sleep. This will happen over a few days, until you fall asleep. Your body will begin to realize it is dying, and release its natural endorphins to help with the pain. We’ll give you pain medications until that kicks in.” As we walk down the hall, he explains to me, “Kidney failure is a good way to die. It’s quite peaceful.”

By the end of the week I am appreciating the teamwork of the NP and attending. She gets things done around the dialysis unit, puts in orders, and helps organize the nephrologist. When a consult comes in for something atypical, the consult is sent to the nephrologist. During rounds she will ask about the management of these patients, and seems to learn something new every week.

After work, Sarcastic Samantha, Lanky Luke and I grab drinks with the nephrology NP at our favorite burgers and beer joint. Samantha comments how she does not see many PAs and NPs that are happy in their job, including herself. The nephrology NP responds, “I’ve gone through so many mundane ACP [Advanced Care Partner] jobs in which I was miserable. It’s all about finding a partner in a doctor. I think that’s the beauty of the ACP is that you can mold into the role – find your niche. You need to find a physician that will build you up so you are a smooth team.” She adds, “We are trying to hire another ACP to work under me. The problem we have is that new ACPs switch jobs so frequently it’s hard to justify investing time in them.”

Statistics for the week… Study: 2 hours. Sleep: 8 hours/night; Fun: 1 night. Jane and I went on a weekend Airbnb cabin getaway.

The rest of the book:

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Medical School 2020, Year 4, Week 9 (Urology Week 2)

I am in the OR with Coach K on Monday and his partner Comedian Tom on Tuesday. I see three TURPs (transurethral resection of the prostate) on each OR day. After the patient is under general anesthesia (anesthesiologist chooses between endotracheal tube versus LMA) and draped, Coach K inserts the rigid cystoscope into the urethra. He points out several anatomical landmarks in the urethra and bladder on the screen. He points on the screen to the verumontanum, a subtle elevation of tissue identifying where the ejaculatory ducts enter. “As long as we remove tissue distal to the verumontanum, the patient should recover full control of the bladder. The external urethral sphincter and levator ani (pelvic floor) are just proximal to this landmark.”

He inspects the bladder, there are trabeculations and several indentations into the bladder surface. I ask why they’re there. “The bladder, like any muscle, hypertrophies from the increased pressure trying to push urine through the prostate obstruction.” The diverticula look exactly the same as a patient with diverticula of the colon. He withdraws the scope to the prostatic urethra, inserts an electrocautery device, and uses its 5mm-diameter semicircular wire to cut through the urethra and prostate to open the channel.  As he shaves the prostate, a few bleeders are seen piercing through the clear water. He cauterizes the bleeding vessels. “The prostate is a poorly perfused organ so there isn’t that much bleeding when you cut into it; these bleeders are perforators.”

The nurse periodically hangs another bag of 7.5 percent glycine on a post near the OR table. A tube flows down to the scope to keep the bladder distended so we can see the entire prostate. Coach K explains that we use glycine because the electrocautery device would not work in saline. “The current would not be discharged to the local targeted tissue, but instead be conducted through the salt water. Glycine does not conduct so the path of least resistance is to whatever tissue is touching the wire. If we are just scoping the patient we use saline. Pure water would work, but it would kill cells from the osmotic pressure gradient. There is a small risk of hyponatremia [low blood sodium] after these procedures which is why we try to keep the irrigation time under 1 hour.”

There was a noticeable contrast between Coach K’s technical skills in the TURP versus Comedian Tom. Coach K carved out the prostate creating an elegant circular channel that was all cauterized with no bleeders. I felt Tom struggled to get good visualization during the procedure because he couldn’t completely coagulate off the bleeders distorting the picture. He didn’t “butcher” the patient, but it wasn’t as technically satisfying. I couldn’t tell if the channel was circular or how much he removed at the end. His patients still get benefits but I wonder if they have different 10-year outcomes. Coach K:  “90 percent of patients at 10 years after TURP do not have any obstructive symptoms. 10 percent get regrowth that requires either medical management or re-operation.”

Although these doctors operate at our hospital, they are partners in their own practice. “Private practice is hard. There is a reason it’s a dying breed,” Coach K explains. “We are clinging to paper charts for as long as we can. EMRs are so expensive for a small practice such as ours, but we also get penalized by Medicare for not having meaningful use.”  He picks up a patient’s folder. “This patient was admitted for an obstructing stone. I was called in and removed the stone. Here is the fax from the stay. Is this meaningful?” He hands me a 25-page print out from our hospital’s Epic EMR for the two day admission. The first five pages are demographic information, mostly blank (e.g., address 1 filled in, addresses 2 and 3 unfilled). There are numerous nursing notes, a CT report with paragraphs describing how radiation exposure was minimized, and his operative note. “This is all checking boxes. You cannot find actionable information.” When patients come to his private office for a follow-up after hospitalization he ends up throwing nearly their entire hospital record into the protected health information (PHI) shredder bin.

Another assault on his income is that our hospital has gradually bought up clinics and practices to form a regional health system in which providers are encouraged to refer to specialists within the system. The private practice doctors end up with the worst parts of working for the hospital, e.g., taking call, and none of the benefits. The private partners are also at a disadvantage when purchasing supplies, sometimes resorting to Amazon for scarce items.

[Editor: this was before the “supply chain” catastrophes that started in 2020]

Our last patient is a 73-year-old self-deprecating truck driver who walks in with a USA 45 hat. He has classic symptoms for BPH and an elevated PSA. He introduces himself, “I’m all healthy doc, except for my pee-pee.” The nurse measures a post void residual of 490 mL (this is pretty close to what would be considered full in a healthy individual; less than 50 mL is considered normal). He explains to me that he drinks 2 jugs of coffee to stay awake on his daily 8-hour drive. He sleeps with one of the cups due to fear of urgency and leakage. We start him on tamsulosin, and schedule a one-month follow up appointment.

One of our classmates just matched into urology. Coach K helped mentor him so is quite proud. My classmates meet at Buff Bri’s house for a penis celebration. Sarcastic Sally gets decorations from a bachelorette party store, including penis hats and straws. Mischievous Mary brings assorted nuts for snacking. We reflect on senioritis. Pinterest Penelope summarizes: “I have instagram and snap chat to deal with. I can’t be at the hospital.” Mary shares her latest experience: “I was doing an APR (abdominal peritoneal resection, removal of the rectum and anus) with a jewish colorectal surgeon and a resident. The Poop Doc was across from me, while the resident was in between the legs struggling to remove the rectum through the anus with all his might. Poop Doc: ‘You can help the resident  by pushing on the abdomen from above.’ As I do this, the rectum shoots out with liquid poop, which seeps down the resident’s gown. The resident exclaims, ‘It’s in my socks!’ Poop Doc, ‘Oy vey.'”

Statistics for the week… Study: 4 hours. Sleep: 7 hours/night; Fun: 1 night. Penis party.

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Medical School 2020, Year 4, Week 8 (Urology elective Week 1)

I meet my attending, Coach K, in the four-urologist private practice at 8:30 am. The radio is tuned to the sports channel as he signs paperwork before the first patients are ready. “If I can get you to not consult urology when you cannot pass a Foley, you have had a successful rotation.”  (A Foley catheter drains urine directly from the bladder.) His new nurse is a friendly 63-year-old. Nancy retired after working 25 years in a family practice office, but returned to work because “my husband was driving me crazy with us both sitting at home with our kids out of the house.”

Nurse Nancy explains that Coach K likes to stay busy. He usually double- or triple-books each 15-minute appointment slot. This is plenty of time if Nancy is able to get a urine sample and the post-void residual bladder scan in a timely manner because most visits take less than five minutes. For example, if following a patient for elevated prostate specific antigen (PSA), Coach K will ask if there are any changes since the last visit, and then recount the options of biopsy versus active surveillance (PSA every three to six months). He says farewell, while Nancy draws blood for a lab company rep to pick up at the end of the day. 

Urologists see a wide spectrum of ages. Most patients are between 50 and 75 years old referred for either elevated prostate-specific antigen (PSA) or difficult-to-manage benign prostate hypertrophy (BPH). We see patients of all ages for kidney stone management. Young couples come in for vasectomy referrals. A vasectomy is a 10-minute office procedure done under local anesthetic. Coach K offers a valium to take beforehand in which the patient has to have someone to drive him home. I see a 29-year-old male accompanied by his wife and the mother of their five children. Coach K asks if they are sure they do not want any more children. When they learn that he could come in alone, the wife responds, “Oh no, I’ll be here. I have to make sure he goes through with it!” Coach K explains, “You will need to use protection for three months. After that he will drop a semen sample off here so we can test it to ensure there are no sperm present.”

[Editor: See also “Hamptons bachelors are getting vasectomies so gold diggers can’t trap them” (New York Post, May 27, 2017). “‘There’s a spike in single guys’ who get the procedure in spring and early summer, said Dr. David Shusterman, a urologist in Midtown. ‘This extortion happens all the time. Women come after them. [They get pregnant and] want a ransom payment,’ said Shusterman. ‘Some guys do an analysis of the cost — for three days of discomfort [after a vasectomy], it’s worth millions of dollars to them.'”]

We see roughly eight benign prostate hypertrophy (BPH) patients per day. Coach K: “10 percent of men at 50 will have obstructive symptoms, 100 percent by 80.” When asked about symptoms of obstruction, patients lights up as if saying with their face, “Finally, someone understands what I am feeling!” Obstructive urinary symptoms include: sensation of incomplete emptying, double voiding, dribbling, and decreased force of stream. A lot of men report having to get up in the evening. I learn that this is more related to irritative symptoms or excess urine production from mobilizing fluid while laying flat. Coach K explains, “Put your feet up 30 minutes before bed so you can pee off this fluid before getting into bed.” Most men’s BPH can be managed with medicine, either an alpha-1 blocker and, if needed, finasteride. Finasteride takes 3-6 months to have an effect as it lowers DHT levels that drive the growth of the prostate. Coach K explains, “The main side effect of finasteride is decreased libido, but most people are fine.”

[Editor: Reduced male libido may not be a problem: “Only 48% of married women want regular sex after four years.” (Good Housekeeping)]

My attending continues, “One controversial topic is whether finasteride increases the incidence of aggressive prostate cancer. The jury is still out.” If these medicines do not control the symptoms, Coach K discusses surgical options including transurethral resection of the prostate (TURP, pronounced “terp”) or a green light ablation. In theory, a primary care provider should be able to manage BPH, but several patients report it is easier to schedule an appointment with a specialist. “The earliest appointment was in four months for my PCP,” states a 62-year-old.

Patients are cheerful during their one-week post-op visits after TURP. “Doc, I feel like a teenager again!” exclaims an 80-year-old man. “Doc, one more question. Do our balls sag when we get old? Every time I sit on the toilet they touch the bowl!” His wife slams her hand on her face. Coach K responds: “Everything sags when we get older.” Another post-TURP patient exclaims, “Finally, I can go on my dream trip to the Canadian Rockies.”

A common complaint during office visits is the cost of erectile dysfunction medications. Although generics have been available since 2017, our older patients can’t figure out how to avoid being charged $300. Coach K: “I tell patients to always ask for the cash price and use GoodRx. In a study of the five most commonly-prescribed urologic medications, CVS was by far the most expensive. Walmart and Kroger were in the middle of the pack. Mom and pop pharmacies were the cheapest.” What about the Aetna-CVS merger? “It’s been terrible. Our office gets called by Aetna all the damn time telling us to switch a patient’s medication [to a cheaper generic-available drug]. The patient could be on the med for the past 15 years.” He is adamant. “No, I am not switching them, there is no medical reason.”

We see a 62-year-old patient whom I cared for six months earlier in the surgical ICU. A tractor rolled over him and fractured his pelvis. It was nice to get to know him as a person since he’d been delirious for his week-long ICU stay. Since discharge, he has been working with physical therapy, and is now able to use a walker. His wife asks if there is anything to help with control of his bladder. When he does any activity, e.g., rises from sitting, coughs, or laughs, he leaks urine. For two months he also had fecal incontinence, but this has slowly resolved. Coach K instructs me to perform a digital rectal exam (DRE). He has no rectal tone, and no bulbocavernosus reflex (squeezing head of the penis should lead to squeezing anus). He has damage to his pelvic floor muscles. “This might get better, time will tell and there is really nothing for us to do to make it go quicker.” We prescribe him Sudafed, a stimulant that can improve urethral sphincter tone. “It’ll make you feel jittery, but take it 30 minutes before you work with PT. It should help with leakage.” We also see several bed-bound patients that need a Foley exchange. 

Twice a day we see a child for bedwetting. Coach K explains that secondary nocturnal enuresis, in which the patient at one point did not wet the bed, is almost always a result of trauma, e.g., sexual abuse or parental divorce. “There is nothing we can do for them except try to reduce their stress level,” he says.  Most of the time this is for primary nocturnal enuresis (bedwetting since birth), for which Coach K explains that we are also without medical interventions.

[Editor: But not without an ICD-10 code and an insurance reimbursement!]

A 7-year-old female who has been potty-trained since 2.5 is brought in for bedwetting. “You’ll hear the same spiel as last time,” says Coach K. He explains to the family that this is a common issue due to immaturity of the connections between the brain and the bladder. The condition is strongly heritable and usually at least one parent recalls having been a bedwetter. Deep sleepers are more vulnerable to this condition. Do you have trouble waking her up in the morning? “Oh yes, she is such a deep sleeper. She won’t wake up from anything.” Coach K explains, “Bedwetting gets better with time. Only one percent of 18-year-olds are still wetting the bed, but the improvement will be gradual, coming down from 4-5 times per week to 2, to once per week to once per month.” Behavioral modifications, such as decreasing fluid intake between dinner and bedtime and restricting caffeine, will decrease the amount of urine produced at night, but won’t reduce the number of events per week. He hands the family a small pamphlet for a bed alarm. The bed alarm senses fluid and wakes the patient up. “It won’t stop the bedwetting,” Coach K explains, “but will make it more manageable for motivated children.”

Why not offer them medications? Coach K later explains to me that the success rate of DDAVP (desmopressin) is so low that parents get more discouraged when it fails. 

Later, I see a one-percenter: a fit 19-year-old freshman sporting a well-groomed large beard followed for primary nocturnal enuresis for over a decade.  Coach K asks how college is going. “I’m studying construction engineering. Math was always easy for me in high school, but I am struggling to stay afloat for some of these classes.” He’s in a “Live and Learn” community that should be supportive. In high school he tried imipramine, an antidepressant (TCA) that has side effects of bladder retention, which did the trick. He went from 5 events per week to 1 per week. He gave up the drug due to its side effects and now wets the bed 3 times per week. “I am sure this is a killer to your social life,” says Coach K. The patient asks to go back on the medicine and Coach K prescribes him a half-dose, emphasizing, “Keep in mind alcohol will make this worse. It puts you into a much deeper sleep.”

We see five bladder cancer surveillance patients per day, all of whom are former or current smokers (a big risk factor due to irritation of the mucosa). Bladder tumors are mostly diagnosed after gross hematuria (visible blood in urine) or persistent microscopic hematuria on urine dipstick testing. As long as the tumor is superficial, and does not invade the smooth muscle, treatment is removing it in the OR through cystoscopy (fiber optic scope with a cutter at the end). After the initial diagnosis, the patient is screened for recurrence every three months for one year, followed by six months for four more years, and then yearly. “I have patients that I find a recurrence every six months, and I have patients that are clear for a decade, and one pops up.” The first cystoscopy is alarming for both men and females. The patient is prepped in the procedure room with a drape over their exposed genitalia. Coach K inserts numbing gel into the urethra, followed by a flexible scope. When he sees an interesting finding, he signals me over to look into the scope.

[Editor: Bladder cancer patients seem to generate annuities for urologists. In 2012, Forbes noted that “These specialists earn an average of $461,000, not including production bonuses or benefits.”]

Statistics for the week… Study: 3 hours. Sleep: 9 hours/night; Fun: 2 nights. Taco and tequila bar with Straight-Shooter Sally and her boyfriend, an engineer for a green energy design firm.

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Medical School 2020, Year 4, Week 7 (Interview Prep)

Interview season has commenced, which means we get days, weeks, or even a month off to travel to residency programs. With the exception of a few specialities such as urology and ophthalmology, the Match starts when the Electronic Residency Application Service (ERAS) opens at the beginning of September and interview offers start shortly after the end-of-September application deadline. The application includes volunteer and professional experiences, research publications, and letters of recommendation from attendings. A letter from one’s medical school dean is required, but we are told that this is ignored by programs. We also have to submit a personal statement. Popular topics include challenges overcome [Editor: a victimhood narrative!] and motivation for becoming a doctor (“earn money” will not appear here). The less competitive programs will send their interview invitations first.

Students apply to as many as 90 programs and even more if they are applying to multiple specialities. Our Dean of Student Affairs sent an email out overviewing the process, highlighting that we are nearly guaranteed to match into a chosen speciality if we interview at 12 or more programs. “If by December 1st you do not have that many interviews, contact me.”

Most programs email four interview dates that fill up within hours. The Dean of Student Affairs recommends giving login information to a trusted family member to accept interviews as they come in case you are in the operating room and don’t open the email soon enough. One program sends more interview offers than slots. Lanky Luke responded within 30 minutes, but “I was waitlisted because they already filled.” Sarcastic Sally empathizes: “This happened to me too! I just don’t understand why a program would leave it to chance to decide who they interview. Select the better candidate. I don’t buy it that someone who responds within 30 minutes shows more interest in coming than someone who doesn’t respond for an hour.”

Every specialty and program has different interview date ranges. Our dean explains that around 2010 there was a movement to cluster interview dates by region to allow for decreased travel costs. For example, southwestern surgery programs would have their interviews clustered around one week but coordinated to avoid overlap. “They no longer do this,” said the dean. “Expect to spend $7,000 to $10,000 during interview season on hotels, cars, and airfare. This has been budgeted into the MS-4 cost of attendance so you can borrow more money if needed.”

I’m applying to general surgery, which requires 4 recommendations. Mine are from three surgeons, a research mentor, and, unconventionally, an internist with whom I worked frequently.

Statistics for the week… Study: 5 hours. Sleep: 7 hours/night; Fun: 2 nights. Dinner party with Lanky Luke and Sarcastic Samantha.

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Medical School, Year 4, Week 6 (Cardiothoracic Surgery, Week 2)

I’ve now done enough coronary artery bypass graft (CABG) surgeries to learn the typical sequence:

  1. Surgeon arrives for “time out” (checklist review to prevent, e.g., wrong side operation), then leaves the room for the physician assistant to harvest the saphenous vein. The anesthesiologist performs a trans-esophageal echocardiogram to visualize pre-graft cardiac function.
  2. Surgeon reappears for scrub-in.
  3. I struggle to find space for myself between the perfusionist console and the surgical tech table while the surgeon and PA make the incision and perform the sternotomy.
  4. I watch from behind as the surgeon harvests the left internal mammary artery (“LIMA”, however the latest term: “left internal thoracic artery”)
  5. Surgeon has me switch with the physician assistant (PA). Surg tech hands me the cannulation equipment
  6. Surgeon tells me where to pick up the pericardium with the DeBakeys (non traumatizing forceps) to apply tension. The surgeon incises and throws sutures into the pericardium. We grab the sutures to fold back the each side of pericardium for better visualization of the beating heart.
  7. Cannulation time: the surgeon throws circular sutures (one or two, depending on preference) into the aorta and right atrial appendage. The heart is beating so the surgeon times the throws (needle push through tissue) based upon the relaxation of the heart. Once thrown, I grab each suture, cut the needle, and thread the suture through a rubber tube. I hand the surgeon the venous cannula, and he punctures the right atrium in the marked circle. I then pull the suture tight while pushing on the rubber tube. This tightens the suture around the cannula to create a seal. Repeat on the aorta. Every time I touch the heart, the screen shows an ectopic beat.
  8. We clear the air from the tubes and clamp the aorta proximal to the aorta cannulation site. The surgeon announces to the perfusionist to go “on pump”. The surgeon will tell the perfusionist to infuse cardioplegia (cold solution of high potassium) that paralyzes the heart. Blood pressure flatlines at around 90mm of mercury (as opposed to the usual rise and fall with the heartbeat).
  9. Anastomosis: The surgeon identifies areas to bypass the blockages. While he looks, I ask to make sure I know what vessel he is thinking about. “That’s the Left Anterior Descending artery?” He responds, “No, he has a small LAD, this is actually the OM1.” The surgeon and PA wear loupes to see the 6-0 suture (0.33mm diameter) to bring the vessels together. First is the graft-coronary anastomosis, then the aorta-graft anastomosis. The PA “follows” the surgeon’s throws to prevent “locking” the suture. I use the “blower” to blow a thin stream of air into the field to provide better visualization of the vessels (one attending barks at me: “it takes forever to de-air the left ventricle”). I am also in charge of squirting water onto the surgeon’s hands while he or she ties the suture. Each anastomosis takes about 10 minutes and is done in a quiet OR.
  10. Anastomosis is complete. Surgeon uses a doppler to confirm patency and good flow.
  11. Anesthesiologist reports on cardiac function. Frequently, there will be immediate improvements in the regions that were impaired. 
  12. Surgeon inserts ventricle and atrial pacer wires and pushes them out through the skin. 
  13. Surgeon inserts drains (“chest tubes”) into the pericardial and pleural spaces. The nurse connects them to suction.
  14. Perfusionist stops cardioplegia, and warms the blood. The heart begins to beat slowly, then goes into ventricular fibrillation. The surgeon takes the paddles and defibrillate the heart into sinus rhythm.
  15. Surgeon closes the sternum with stainless steel wire and scrubs out.
  16. Time to close. Usually I work with the 45-year-old head surgical PA, who patiently tries to teach me all of her chest-closing tricks. “We close differently than downstairs [in general surgery]. In the thorax, no space is allowed or it could blow up into a raging infection.” She instructs me, “Take smaller bites.” We close in multiple layers, typically 3-4 to ensure there is no potential space for fluid to accumulate. After the second operation, I am able to close three inches of the 10-inch incision before the PA meets me in the middle. “Good job, you are teachable.” (on the first two, she redid my sutures because they were too far apart)

Medical students are required to skip cases on Thursday to attend a Dean’s session highlighting a “medical topic of critical importance,” one of three each year. The topic this week is “LGBTQ myths and medical miracles” and the speaker (“Dr. Castro”) is an internist from San Francisco. “How many of you have heard of Stonewall Inn? This is recognized as kicking off the Gay Pride and fighting for gay rights. I went to medical school in the 1980s. We had a psych lecture titled, ‘Homosexuals, pedophiles, and beastiality.’ I give this timeline to highlight the challenges people have overcome, and the amazing change in perspective in such a short amount of time. I want to remind everyone that this fight is still ongoing. Look at Pulse Nightclub, an evil that should shake every American. Look at Trump trying to say sex is not gender identity, and that anti-discrimination laws do not apply to us.”

[Editor: Why would LGBTQIA+ community members want anti-discrimination laws to apply to them? Generally these laws cover classes of workers whom employers regard as inferior, e.g., older or disabled workers, racial groups with low academic achievement, etc. Would it help gay physicians, for example, if the government officially says “Because of their evening sexual activities, these doctors will not be able to treat patients as well and therefore you shouldn’t hire them unless you’re forced to”?]

He pauses. “How many of you are in a target group?” Half of the hands go up. Dr. Castro: “Every single one of you should raise your arm. Every woman should raise your hand, you don’t get equal pay for equal work. If you have any degree of pigmentation in your skin, raise your hand; you are a victim.”

The first slide contains only the text, “If we can get to sensitive.” Dr. Castro asks the class, “Let’s say a close friend came out as gay. How would you feel?” The first answer, “I would not care,” turns out to be wrong. “Embarrassed he did not tell me sooner,” and “Proud they trusted me” were received with approval.

Nobody was willing to go on record with an anti-gay sentiment, so the speaker had to step in and play the role of the prejudiced. His stereotypical anti-gay sentiments included “They walk around in Speedos at Pride festivals,” and “Are children raised by gay couples at a disadvantage?”

[Editor: “Growing up with gay parents: What is the big deal?” (Linacre Quarterly 2015, a bioethics journals) reviews the research on the last topic. Sample:

A 2013 Canadian study (Allen 2013), which analyzed data from a very large population-based sample, revealed that the children of gay and lesbian couples are only about 65 percent as likely to have graduated from high school as are the children of married, opposite-sex couples. The girls are more apt to struggle academically than the boys. Daughters of lesbian “parents” displayed dramatically lower graduation rates. Three key findings stood out in this study: children of married, opposite-sex parents have a high graduation rate compared to the others; children of lesbian families have a very low graduation rate compared to the others; and children in the other four types of living arrangements (common law marriage, gay couple, single mother, and single father) are similar to each other and fall between the extremes of married heterosexual parents and lesbian couples.


Dr. Castro explains, “One of the critiques from last year’s session was that there wasn’t enough medicine in this talk. So let’s talk about some of the medical treatments available for gender dysphoria.” Slide with two columns:

Gigolo Georgio asks, “Does insurance cover these treatments?” Dr. Castro: “Right now typically not, but we can get around this sometimes by using a different diagnosis. For example, a patient may have a fibroid that wouldn’t typically be an indication for a hysterectomy, but under this situation it can be. Or if the patient has a questionable breast mass, we decide that it should be removed.” The big event recently is we now have a DSM code for gender dysphoria. If we as advocates continue to persist, insurance companies will eventually pay for treatments with this DSM code.”

[Editor: “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden” (2011): “Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.”]

Dr. Castro talks about the challenges faced by his transgender patients: “My patients usually shy away from the spotlight.  They work night jobs, or at a call center. Several are truck drivers. All transgenders are marginalized early which leads to distrust in systems, including the medical system. Many were kicked out by their family, had trouble finding a job, many drop out of school due to bullying. One in four attempt suicide by 25. One in five who come out are kicked out by their PCP. There is no way to reverse this overnight.” Type-A Anita is the first to respond. “How do we fix this?” Dr. Castro: “It will take concerted effort. For example, educating medical staff on proper pronouns, and redesigning medical forms and EMRs into gender neutral forms.”

Statistics for the week… Study: 6 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun. Jane, Luke, Samantha, and I grab beers and burgers. Samantha gets $5,000 per year for CME at her HCA hospital job. She and a colleague (also a PA) just returned from a hospitalist conference in Oregon.

Over dinner, we discuss media coverage of hospitals taking poor patients to court and garnishing wages. A large academic center (University of Virginia) was featured for pursuing patients whereas the for-profit HCA hospital was more charitable. Samantha: “HCA doesn’t divert. We will accept any patient even if our hospital is full. It is so bad right now that each hospitalist has 27-30 patients.” Jane, “I can’t even keep my 2-3 patients straight.” Jane continues, “The ED is full, we have patients being admitted, treated, and discharged all in an ED bed. It got so bad once that we converted the cath lab into beds. I have 17 patients. The hospitalists who are in charge and technically sign orders and notes for billing don’t ever see my patients.”

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