Medical School 2020, Year 4, Week 35 (Advanced Anatomy)

It is March 30, 2020. Our rotations are now “socially-distanced”: medical education (Zoom meetings with M1s and M2s), pathology (share a screen with a pathologist), and anatomy (handful of masked people in a large lab). The most popular choice is an additional two-week block of “study time” (i.e., vacation) for the Step 3 exam, a two-day multiple choice exam that costs $895 and duplicates material from Step 2. It is impossible to register for the exam until after we graduate, so nobody is actually studying. Jane and I have decided to learn anatomy from our favorite retired trauma surgeon for two weeks.

There are just two other students on our elective, including Buff Bri who matched into neurosurgery and a Canadian who matched into Internal Medicine. School administrators have decreed that everyone wear masks in the anatomy lab and that no more than two students at a time can be present in the thoroughly ventilated cavernous anatomy lab. Jane: “I’m surprised that our professor is teaching. She’s the ideal patient to actually be harmed by COVID-19.”  We will meet five times over two weeks, starting at 10:00 am and working until the early afternoon.

The first week we focus on trauma exposures. Jane and I start Monday on a cadaver with an untouched abdomen! Our attending first goes over how to make a midline incision. “A lot of residents do not extend the incision all the way to the xiphoid process. That few extra centimeters gives you a much better exposure.” We both take turns cutting, then suturing each fascial layer back together, and then cutting the sutures. Next we play the “Exposure Game”: she tells us an organ or structure, and we have to describe how to get to it once inside the peritoneal cavity. We perform the Kocher maneuver, medialization of the duodenum through incision of the inferior lateral border of duodenum, and the Cattell-Braasch, medializing the lateral edge of the ascending colon. A typical abdominal organ can be mobilized (or “medialized”) from its natural resting place by incising a thin layer of connective tissue (“peritoneum”) thereby releasing its long blood supply attachment (mesentery) to its full length. From this principle, you can bring the right colon or spleen out of the abdominal cavity while still attached to its blood supply. 

We quickly realize that the cadaver’s anatomy is way out of whack, which makes winning the game a lot more challenging. There is a seven-inch predominantly solid mass in her midline, which encircles the aorta and pushes her vena cava to the right. We cannot identify the abdominal aorta at all, but slowly dissect it out moving backwards from the bifurcated right and left iliac arteries. We also perform the Mattox maneuver in which the left colon and kidney are medialized to reveal the aorta.

We go in Wednesday and Thursday to continue to dissect the abdomen and remove the mass. During our dissection, we find that she had a ureteral stent placed in her left ureter due to obstruction from the mass. Our professor hands us a bucket to save the specimen for future classes. “Next year’s class wont have cadavers because authorities are requiring all cadavers be Covid-negative. There just won’t be any supply.”

We then perform a resuscitative thoracotomy (creating a hole in the chest). I make an oblique incision from below the nipple to the sternum, dissect down to the ribs, and place a rib expander (“Finochietto”) device in between the two ribs. Jane starts turning the crank to expand the ribs apart. We switch and Jane takes over to dissect out the heart and lungs. “Bedside thoracotomy is a procedure that is a last ditch effort to bring a trauma patient back from death,” our attending explains. “Imagine a 30 year old with multiple stab wounds is dropped off at the ED entrance. He is in extremis – he doesn’t open his eyes and is groaning only. His heart rate is 160, and the automatic BP cuff cannot get a reading. He has a pulse when he is transferred over to the trauma bay bed, but shortly thereafter, an astute medical student says that she cannot feel a pulse. What do you do?” A resuscitative thoracotomy is performed to try to bring this dead patient back to life. A large incision is made, the ribs are spread. The heart is delivered out of the chest. The aorta is clamped to decrease the circulating blood volume and divert blood flow to the brain. Frankly, attendings sometimes let residents do it to practice even though it doesn’t significantly improve patients’ outcomes.” She concludes, “The best evidence suggests performing resuscitative thoracotomy after traumatic arrest from penetrating injuries to the chest – maybe you can stitch a hole in the heart – or penetrating injuries to the abdomen where you can halt massive hemorrhage by clamping the aorta.”

On Friday, we perform a mastectomy, much to Jane’s disappointment after her two-week breast service rotation. “After a few mastectomies, it is boring. You’re just cutting into fat.” I make an oblique incision along the cadaver’s breast and find the pectoral fascia (connective tissue plane overlying the pectoral major muscle). I then dissect, mostly with my hands, to remove the breast tissue (all fat in this 86-year-old). We then perform the much more exciting axillary lymph node dissection! Jane begins it by reflecting the pectoral major to identify the clavipectoral (“clavipec”) fascia which runs up to the coracoid process (bony protuberance on the front of your shoulder). “The coracoid is the key to the axilla,” exclaims our attending. Jane and I have not studied this anatomy for awhile, having not been in the hospital since almost January, let alone on a surgery rotation. We pull out Netter’s Atlas of Human Anatomy, multiple copies of which are strewn around the lab, and turn to the axilla plates. We receive a ten-minute tangent about the most important books for surgeons to have: Netter’s Atlas of Human Anatomy,  Maingot’s Abdominal Operations, Skandalakis’ Surgical Anatomy, Netter’s Surgical Anatomy and Approaches.

We review the shoulder anatomy, and head back to our dissection. “In an axillary node dissection, you typically should not see the neurovascular bundle. You mostly have to watch out for what two nerves?” Jane responds, “The thoracodorsal (latissimus dorsi) and the long thoracic (serratus anterior).” Women are already self-conscious enough about losing a breast. It’s best not to also give her a winged scapula [injury to long thoracic nerve leading to impaired function of the serratus anterior].” 

Buff Bri comes in every day for several hours, defying social-distancing orders from the administration, but our elderly trauma surgeon doesn’t care (“the cadavers are far enough apart”). From the first two cadavers he removes the brain by removing the skull and cutting the brain stem from the spinal cord. On the third cadaver, however, he spends hours meticulously dissecting out each vertebral arch/lamina to have an undisturbed nervous system from the brain to the end of the spinal cord. When it was time for final removal, our attending hands him the scalpel. “You know what to do.” He shrieks, “No, no, I can’t! You do it!” After a few more shrieks, he begins cutting each of the spinal nerves to finally remove the entire central nervous system – the brain connected to the spinal cord. I am amazed how small it looks. “We’re saving this one,”  as she grabs a bucket. “Not a bad haul for two weeks. Two interesting specimen buckets!”

Type-A Anita is actively sharing “Sassy Socialist Memes” on Facebook. She adds her own gloss: “People, if we’re afraid that giving people $600 per week in unemployment benefits will stop them from working, that’s an argument for raising wages, not for refusing to bail out the people!” If any of her friends are turning to her posts in hopes of reassurance regarding coronavirus, they will be disappointed: “viruses can mutate into different strains. Look at how hard it is to guess which flu strain to account for in annual vaccines. We just don’t know enough about this virus to assume anyone is immune.”

During small group sessions, Anita frequently expressed her hatred of immunology (e.g., “Who cares about CAR-T cells and HLA types?”). A classmate who has specialized in immunology responds to Anita’s fear of lethal mutations: “The mutation rate of this virus is orders of magnitude less than either the flu or HIV, two viruses that have much more genetic diversity than SARS-CoV-2 due to extremely error-prone replication machinery. This bodes well for development of effective vaccines and possibly antibodies in comparison to circulating influenza viruses. Doesn’t change the fact that the duration of post-infection immunity is unknown, though!”

[Editor: Maybe they were both wrong, like most people who made predictions about COVID-19. SARS-CoV-2 never mutated into a virus capable of killing people with different characteristics than the early victims (i.e., the death rate kept falling because the virus killed those susceptible to death in the first year or two). But the immunology nerd was also wrong. We never developed a vaccine that reduced infection or transmission and maybe the vaccine had no effect on the death rate either. See “Where is the population-wide evidence that COVID vaccines reduce COVID-tagged death rates?” and “Did vaccines or any other intervention slow down COVID?”. Anita’s prediction that Americans would go back to work after long-term unemployment was at least partly wrong. Bureau of Labor Statistics data showed that the U.S. labor force participation rate remained lower in 2023 than it had been in 2019, though the most dramatic fall was from 2009 through 2015, after the 99 weeks of unemployment authorized by Congress during the first weeks of the Obama administration (“99 weeks of Xbox”).]

Statistics for the week… Study: 0 hours. Sleep: 9 hours/night; Fun: 2 nights. Jane and I continue packing up our house and training our two puppies. We go to the dog park every other day.. Pinterest Penelope ordered graduation-themed tee-shirt pullovers for each dog and arranged a class dog photoshoot. Wine night every night.

The rest of the book:

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Medical School 2020, Year 4, Week 33 (Residency Prep, week 1)

Six weeks until graduation. Before the last two-week elective, we have four weeks of Residency Prep (“RP”). It is March 16, 2020, and the deans are changing policies every few days, trying to stay ahead of COVID-19. M1 and M2 classes have been on Zoom for a week. Lanky Luke was facilitating an 8-student “Medical Education” elective. “Life is pretty normal for them,” Luke said. “Less than 10 percent of the class even went to lecture pre-COVID-19 so they are used to it.” He adds, “It’s odd to see people in pajamas. I don’t complain! I am too!” 

M3s are the most affected. Initially, their rotations continued, with instructions to stay out of rooms that require PPE (gowns, gloves, masks, etc.). Students are forbidden to take care of any COVID-19 patient, although our hospital has only one, a 91-year-old woman in the ICU transferred from an outside county.

This policy existed for three days.

On Tuesday, we get an email canceling all clinical rotations until further notice. Students are reassigned into non-clinical rotations. Our options: Medical Spanish via Zoom, Pathology via Zoom, Medical Education, and Advanced Anatomy (cadaver dissections; 2-3 students and one teacher in a large lab). We also have the option to take another two weeks of research or study time (a.k.a. “vacation”). Mischievous Mary is quite annoyed as she has to complete a “medical” elective before graduation so she doesn’t have the vacation option. She would have done in-person cardiology consults, but instead must do remote pathology. “FML!” she texts.

After communicating to us the critical importance of these social distancing guidelines, the administration summons us all into an auditorium to sit side-by-side and learn about a new policy for Match Day (Friday, March 20). While we breathe whatever viruses everyone else has acquired during various rotations, two deans explain that Match Day will be restricted to class members and essential staff (e.g., Deans and Chairs of Departments). University-sponsored events are now limited to 100 people.

Before the coronavirus, this would be a two-day party starting at 10:00 am with a ceremony in the auditorium. Friends and family would fly in from around the nation, with tickets capped at 10 per student. After speeches by various dignitaries, each student individually goes into a private room to open a printout of a letter  that the school would have received the night before. Students emerge to go up to the microphone and give an Oscars-style talk about how grateful they are to have matched at whatever institution. All of this is recorded on video for posterity. Everyone in the audience toasts with Champagne, followed by a catered reception. Groups of friends, accompanied by their out-of-town visiting family members, go to local restaurants for lunch. The gatherings continue into the evening in restaurant and bar private rooms and patios. There would be brunches and barbecues on Saturday and continuing into Sunday for the hardcore.

We will get none of this.

Chaos ensues as already-anxious students absorb the fact that they will not be able to open their Match letters with family and friends. Students talk over each other trying to negotiate with the deans for 2-ticket or 1-ticket allotments. Nervous Nancy quiets the room. “Some of us have loved ones that are old and vulnerable. This is serious. Let’s just have a small ceremony and leave.” Father Fred, a 30-year-old whose children are now 3 and 6-months old, asks, “Could we can pick up our letters and leave the premise to open with family instead of staying around?” The decision is that we will stay for one hour to hear shortened speeches, and then leave after we are handed our Match letters at noon to open them with loved ones outside. We’ll communicate our Match results to classmates via a group spreadsheet.

GroupMe erupts before Jane and I get to the car. 

Gigolo Giorgio: “PSA: you will get an email from NRMP at 1:00 pm, so you could just wait in bed.” 

Pinterest Penelope: “Another hour of my life wasted.”

Lanky Luke: Question- what if only significant others (perhaps fiancé and spouses or something) are allowed? It would probably be only a few individuals who are mostly local. This option would allow them to enjoy the experience with individuals who are equally impacted by this decision, while minimizing exposure. (likes and “I agree” responses accumulate)

Buff Bri: They really should cut nonessential faculty and staff. We might be able to squeeze a few more in there.

Pinterest Penelope is the camel nose under the tent: Would [Jeffrey] count? He’s not my fiancé, but we’ve been together over four years and he lives here.

Gigolo Giorgio: not opposed to the +1 idea, but still think it needs to be that everyone gets the invite or nothing. just not fair for some people to have their person there and not everyone 

Class president: The other thing we could do, which I have heard students from other schools are doing, is to take our envelopes and have our own [enormous] ceremony and opening party somewhere away from school. we could hold it in [local venue] and rent the space for longer and do everything as planned there.

Nervous Nancy: I’m not sure how great this visual would be if it got out to the public that the esteemed medical graduates are partying it up downtown while pandemic is ensuing. I wasn’t gonna ask my SO to attend cause I really really don’t like ceremonies and I’m immunocompromised [from treatment of Crohns disease]. Basically I totally get that my POV might not be the majority.

Straight-Shooter Sally: Y’all hiding behind your computers and phones acting like we didn’t meet in majority with the deans, talked it through, and decided to play our part in social distancing. We already have it better than so many people. (attaches Excel sheet from reddit with canceled Match days by medical school.)

Fashionable Fiona: If the +1 option is pitched to [the deans] and then shut down, I’m amenable to our leadership then pitching the just SO option for the 30 or so people that have one. I get it’s not ideal or fair for everyone, but I recognize that SOs are as heavily invested in our med school experience and equally impacted by Match day. Just because I can’t have someone there, I don’t want all of you to be robbed of your SO being there. Although if they’re shooting down the +1 option, they’ll likely shoot down to the SO option for similar reasons. But still, maybe worth a shot? Desperate times. 

Gigolo Giorgio: So one student’s SO is more important than another student’s mom or dad? I don’t have any family coming either way, but it sounds like it would be unfair to do just SOs

Gigolo Giorgio: With so many other schools canceling Match day, undergrad campuses closing the campus and having online classes across the nation, and Virginia being in a state of emergency- what makes us the exception? What if the 100 limit is changed to 75 tomorrow? Or 50? I understand we’ve worked for this moment over 4 years and its a once in a lifetime opportunity to celebrate with our loved ones, but we also need to do our part to address this pandemic. Again, my family doesn’t love me enough to come so idc either way

Nervous Nancy:  Tbh y’all I’m embarrassed. The Match is supposed to demonstrate that we are almost doctors, we shouldn’t need the admin to tell us that we should respect social distancing, limit travel, etc. Come on we’re better at epidemiology than this. This a global pandemic out there y’all, people are dying. (And we bitching about our special day being less special for those with [left-home] SOs). Ton of people are not having the special moments that they worked years to earn, for be those moments Athletic or academic, we are doing it to keep people safe. Let’s not be petty, foolish. While probably having a 1+ would most likely be totally OK, imaging how dumb we’re gonna look if something does spread, and it went public that [our school] looked for a loophole with the magic # of 100…. so please pretty please, we are better than this 

Gigolo Giorgio:  “Super spreader event at local medical school: [School] overrules decision to keep Match day private and decide to invite guests! ‘F*ck the virus, I wanna be with my SO if I’m gonna die anyways,’ says a group of students. What a headline.

Ambitious Al: @Georgio you forgot the #YOLO in there 

Buff Bri: Hey everyone! Love you guys and can’t wait for us to all celebrate this next great step 😍 I spoke with [fancy restaurant with fantastic cocktails] and they said that they were ok with having 40-60 of us going to the courtyard at 1PM on March 20th. I know things are constantly changing but I think this will be an awesome chance for us to celebrate over drinks. I will keep you all updated if anything changes, but [restaurant’s] management is aware of Match Day and is very excited to host us

He follows up: Seems like we have almost the whole class who has RSVPed Yes but if anyone else wants to come, let me know!

Fashionable Fiona:: Hi all ~ Now that we *tentatively* have some plans for Match Day, we wanted to let you guys know that we have booked the basement of [local bar/club] (same place we have Halloween!) for our official match night celebration. Given that the yearly school reception has been cancelled (and with it the lovely rice krispie treats) we wanted to have an opportunity to enjoy and celebrate together with good food and drink. Things are definitely fluid right now in [our city], but I have confirmation from [the bar] that they are still allowing events to happen. Guests are also invited but obviously, please do not come/invite your guests to come if any of you are currently sick or are traveling from a high risk area. – We will have a cash bar for food and drinks and rockin’ dance floor! Hope to see you guys there! – Your Match Day Committee 

This week turns into a vacation for me. Residency Prep classes have been rescheduled for next week to allow the IT department to figure out logistics. I go in on Wednesday for individual meetings with two administrators to prepare graduation paperwork, such as NPI and documents that will be needed for state medical license applications.

GroupMe updates from classmates allow us to identify recently stocked stores for hard-to-find goods. Bri: “I found paper towels and toilet paper, but not hand sanitizer.” Jane and I grill with Luke and Sarcastic Samantha almost every evening because the weather is so nice. Samantha is still working as a hospitalist PA: “The hospital is so empty that department heads are asking physicians to take voluntary leave. This is what a hospital should look like. Finally just the actual people who should be in the hospital are here.”

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 7 days. Example fun: Jane and I attend a Thursday party at Buff Bri’s apartment. We set up tables outside for beer pong and spike ball while drinking White Claws and cheap beer basking in the beautiful 70-degree sunshine. Jane and I left around 4:30 pm. We learned that several students went downtown to “support the bars”. Nervous Nancy scolds them over the GroupMe: “I want to thank everyone who is socially distancing and did not go downtown after [Buff Bri’s] party. We are going to be seeing a lot of each other over the next few weeks until graduation, and some of us have loved ones that are vulnerable.”

[Editor: For reference regarding the evolving thinking about social distancing and coronavirus, Li Wenliang warned colleagues about what he believed to be an outbreak of 7 SARS cases on December 30, 2019. China isolated Wuhan on

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Medical School 2020, Year 4, Week 32 (Anesthesia, week 2)

The calm before the storm (March 9-13, 2020). All the talk in the hospital is about coronavirus. Small talk has become easier with physicians able to recycle the same opinions for multiple hall conversations. 

The first patient is getting a surgery for pes planus or “flat foot”. After I place the laryngeal mask airway (LMA; less invasive alternative to intubation, less protective airway that sits above the epiglottis), the anesthesiologist tells me I can do whatever I want today.  “You can stay and hang out with me, or you can try to get some other airways.” I stay for the first 30 minutes and watch as they cut the fibularis longus tendon and then hammer out the joints of the talus with the tarsal bones and then fuse it. It seems medieval, but that’s orthopaedics/podiatry. With another hour still to go, I head to the anesthesia ready room to snag some more intubations.

The admin anesthesiologist for the week is reviewing the OR assignments and a 26-year-old medic in training is sitting on the couch on his phone. “I just need 15 intubations for the month and then I’m done,” he said. “They told me to show up here, but I’ve just been sitting here for 30 minutes.” (By contrast, we medical students are assigned an anesthesiologist via an evening text from the anesthesia coordinator.) We wait for 1.5 hours as anesthesiologists periodically stop by. I ask if they have any intubations, but they are all LMAs.

The senior partner, who is more than 65 years old, is wiping down the keyboards, mice, and handles with disinfectant to cleanse fomites containing the coronavirus (fomite comes from the Latin fomes meaning “tinder,” a term for something that can start an infection first used in 1546 by Girolamo Fracastoro). A 37-year-old anesthesiologist with a thick Eastern European accent tries to warn him. She asks, “What are you doing? We’re all going to get COVID-19 from the Tunnel of Death and elevators.” (The “Tunnel of Death” or “OR tunnel” is the doorway and initial hallway through which patients and staff get to the ORs.)

More anesthesiologists funnel in to join the conversation. There is clear frustration among the anesthesia private practice group that staffs the entire hospital with the hospital’s administration regarding preparation for coronavirus. Several talk about the three anesthesiologists who died during the 2003 Toronto SARS outbreak. The senior partner: “Admins are in charge of the preparation, which invariably means we are screwed, though I am even more concerned about our hospital’s preparation after the meeting yesterday. There is no PPE. We have 8 respirators with only enough parts for 10 uses! I’m not coming in if they don’t get their act together. The administration is already working from home.” A younger new graduate responds, “I’ve lost $30,000 in the market. I’ll take your shifts!” He adds, “I’m still confused whether this is airborne versus requiring respiratory droplet precautions. Unless this is like TB, a surgical mask should suffice.”

The Eastern European: “I am not coming in if we don’t have the right equipment. I’d kill my father in five minutes.” The senior partner continues: “I wasn’t worried about this until I talked to my Italian doctor friend. If over 65 years old, no vent[ilator] for you.” The Eastern European: “It’s the same as dialysis. You don’t get dialysis in Europe if you’re over 65 years of age. And you know what, I can’t judge them when we put 91-year-old grandmas from the nursing home on dialysis.” The young graduate: “This whole discussion was the problem with ACA and the death squad panel. ” The senior partner: “But how much is age predictive of functional status? We see lots of 40-year-olds that look 80. There is just no good way to ration care.” The Eastern European anesthesiologist retorts, “I’m okay being in the death panel!” The young graduate walking to his next case: “Look look, the answer is a chronic disease severity score.”

The senior partner summarizes:  “The administration is useless. If they really wanted to help, get APRV (Airway pressure release ventilation, a mode of ventilation that gives a longer inspiratory time to help fluid filled lungs maintain oxygenation) on the new ventilator machines. It’s just a software update.” Anesthesiologists leave the room for the next case (no intubations…) as one spreads the rumor of a technologist stealing 2 cases of masks last month and selling them for $100 a box (of 20) on Amazon. “The hospital fired him and is pressing charges.”

The consensus opinion is that the hospital will be overwhelmed by COVID-19 demand. We have more than 1,000 beds, but just over 75 ICU beds, and a limited number of ventilators (though possibly a big stockpile of older models in a warehouse). The young guy who was enthusiastic about picking up extra work was the outlier: “It’s mostly going to kill old people.” The senior partner responded, “A lot of us are in that category.”

[One week later, we got our first confirmed case, transferred from a small community hospital in a remote area.]

At 9:00 am, I walk to the endoscopy suite, having heard this is the best place to get high frequency intubations with quick turnover between “scopes” (Esophagogastroduodenoscopy or “EGDs” and colonoscopies) that require ETTs due to position changes. The anesthesiologist in the endoscopy suite runs 4 rooms with the help of 3 CRNAs (certified registered nurse anesthetist). “Fine with me,” he replies when asked if I could join. “What’s your goal?” He quickly grins and says, “Go to room 2 and ask Todd. They do ERCPs [endoscopic retrograde cholangiopancreaticograms or an EGD with cannulation of the bile ducts] in there so a lot of intubations.” Todd, a CRNA, waves me in. I watch the interventional gastroenterologist biopsying a common bile duct stricture caused by a mass. The cases last about 45 minutes and the next patient is wheeled in quickly. I’m able to attempt five intubations before noon. Four go well, but, having failed to visualize the cords well, I mistakenly insert an endotracheal tube into the esophagus of a 40-year-old male with a recurrence of rectal cancer. Todd picked it up quickly before we delivered more than 3 bag breaths, and corrected it without issue. I placed an NG tube to decompress any air in the stomach. I am disappointed in myself, but an important lesson is given by the practical CRNA. “If something doesn’t go smooth, speak up. Never lie.” He continues, “I am amazed how when something doesnt go right, newer crna’s are defensive and withhold information from the anesthesiologist. I think it comes from insecurity. And they weren’t spanked for lying as a kid.”

Our last patient was a 65-year-old with an MI three weeks ago undergoing EGD for cirrhosis. “I don’t know if this patient should be getting an elective procedure right now so soon after a heart attack, but what do I know? I’m just a CRNA. My boss and the interventional gastroenterologist both signed off on it.” I check back in with the podiatry room, then leave at 12:30 pm. 

My intubations improve throughout the week with a clear technique developed and learn how to estimate the correct size of an oral airway by measuring the distance from the patient’s mouth to the tragus of the ear. My last day I got to use the GlideScope, a video laryngoscope. I was able to see the vastly improved relaxation using propofol as the induction agent compared to etomidate (used in shock and heart failure patients). Propofol drops the blood pressure a lot more than etomidate. The attending summarizes: “The most dangerous part of anesthesia is between induction and the operation beginning. Remember sometimes we want the blood pressure to drop during the extremely stimulating intubation.”

The last day of the rotation is at the outpatient surgery center. The pre-op nurse checks in the first patient, a 71-year-old male with COPD undergoing knee arthroscopy, asking if he brought his personal CPAP machine for the post-op recovery nap. The patient’s wife points to a duffel bag on the table. “I’ve never seen a Marlboro CPAP bag!” says the nurse. The patient’s wife responds, “We were such loyal customers that they sent us a bag. And it fits his CPAP machine perfectly!”

The anesthesiologist lets me lead the show. I hook the patient up to the monitor, preoxygenate for several minutes, push the meds that I drew up from the vials, and successfully intubate the patient. The anesthesiologist explains the importance of managing postoperative nausea. Post op nausea increases aspiration risk, impacts patient satisfaction, but most importantly money. He explains, “The post-op area is a high resource area, almost as high as ICU.” Every nurse can have at most two patients. He continues, “A patient with post-op nausea will hold the bed for longer. It’s not uncommon that after the patient is done in the OR, you are twiddling your thumbs in the OR on PACU hold.”

How to assess the risk for post-op nausea? If the patient has the four most important risk factors, there is an 80 percent chance of post-op nausea: (1) history of prior post-op nausea or motion sickness, (2) female, (3) lengthy surgery, and (4) inhalation anesthetic.

How to treat it? There are four treatments for post-op nausea, the most successful being Zofran, glucocorticosteroid, and an extremely low dose of droperidol. (Smoking cigarettes is helpful and supported by research, but no U.S. hospital has thus far set up a designated post-op smoking area.) Droperidol is an antipsychotic (a “typical” antipsychotic, and therefore a strong dopamine antagonist). This is less commonly used even though it has great results because of the antipsychotic term. Everyone is scared of the black box warning for QT interval prolongation (repolarization segment on the electrocardiogram that, if prolonged, can lead to serious arrhythmias). “Funny how the drug got the black box from FDA even though Zofran has the exact same QT prolongation risk. Somehow Zofran as a new drug slipped through it…”

The anesthesia rotation was highly instructive and it seems like a great lifestyle, especially for those who like to shop online from their phones for several hours per day. However, I would never be able to handle the waiting.

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Samantha purchased a smoker for Luke’s birthday. We smoked ribs and “beer” chicken (whole chicken stuffed with a cracked beer to keep it moist) for five hours while drinking beer and the new fad White Claws.  Lanky Luke, having completed anesthesia last month, jokes, “Let’s just say Samantha was not happy seeing our credit card bill after that rotation. I bought so much stuff on my phone during those two weeks.” Their bank account having survived, Sarcastic Samantha is excited to get a new job when Luke matches in a new town. She recounts a typical week at her job as a hospitalist PA rounding on psychiatry inpatients for medical consultations. The 50-year-old female told her, “Doc I need a disimpaction!” Why? “‘I haven’t pooped!” “Let’s start with some laxatives and a suppository first.” The next day, she asked how the suppository went. The patient  responds,”I don’t know.” “What do you mean you don’t know?” “I think I heard two things drop in the toilet.” “Good, good, that means you pooped. Let me know if you need more help.”

She tells us another story from the psych unit: “The next day, my 32-year-old just started screaming on the floor. You could hear her through the double closed door in each room. She wouldn’t shut up. We rolled her onto a sheet, and plopped her on her bed. Wouldn’t stop for an hour.” Since we were outdoors, Samantha gave a demonstration of the screaming volume. “A nurse overheard her whisper to another patient that she was going to pretend to fall and sue the hospital. She doesn’t realize we have everything under video surveillance so we

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Medical School 2020, Year 4, Week 31 (Anesthesia, week 1)

We meet at 7:00 am in the “Anesthesia Ready Room”, a small office with only three computers shared by the 50-person anesthesia private practice. I was excited to be assigned to follow Dr. D, who is widely respected by surgeons. He’s a pale 38-year-old sporting wide circular glasses. We go into OR 17 to set up for the case, a left total knee arthroplasty. He shows me how to pull medications by inserting a needle attached to a syringe into the rubber sealed glass vial. We go over how to pull doses of common anesthesia medications, e.g., succinylcholine, rocuronium, propofol, etomidate. “As a general rule, the right dose is usually half of the vial. That was true during my training, but people have gotten a tad larger now so maybe round up.” He adds, “The exceptions are these.” He points to a nondescript compartment in the anesthesia cart where epinephrine, phenylephrine, and ephedrine are stored. “I’d say the most common medication that I see get overdosed with serious consequences is phenylephrine (“Neo”). It’s meant to be made into a drip (“gtt”, latin for guttae or drops) by inserting the dose into a 100 mL bag for pressor support over time. A typical rate is 100 mcg/min. We use it by giving 200 mcg as a one-time dose for pressor support between induction and the operation beginning.”

“One of the hardest things to do as an anesthesiologist is to do nothing. The patient’s blood pressure drops when we induce the patient. A lot of people want to reflexively fix that with a pressor like ephedrine or phenylephrine,”. Dr. D continues. “Watch how much the blood pressure increases once we start intubating and cutting on the patient.”  We put the pulled medications (in syringes with attached needles) into a locked drawer on the ventilator workstation. He then asks if I have intubated before and with which laryngoscope blade. I respond that I’ve intubated twice, and have used only a “Mac” (MacIntosh laryngoscope features a curved blade versus the straight Miller laryngoscope). “I don’t understand people who use Miller. It’s forcing the pharynx to be a straight configuration when it’s clearly not.” He grabs a “7 French” endotracheal tube (ETT) and Mac 3. I ask, “Should I get a stylet?” (Stylets are a stiff malleable metal wire that is inserted into the ETT to help guide it through the cords.) He laughs, “Stylets are not necessary. It’s $11 that goes down the drain.”

We head to pre-op to consent a 58-year-old for general anesthesia and potential blood products. She is about to undergo a total knee arthroplasty (replacement) with general anesthesia. He asks the patient standard anesthesia questions: any dentures? Previous anesthesia, and if so, any problems? The patient answers that she has terrible post-operative nausea. He asks her to open her mouth wide, and touch her top lip with her bottom teeth (assess range of motion of jaw). She signs the forms, and then the anesthesiologist performs an adductor canal nerve block under ultrasound guidance. A pre-op nurse is dedicated to assist with these nerve blocks. Looking for a good lifestyle job in healthcare? The nerve block nurse’s only job is to wheel an ultrasound cart over and hand the anesthesiologist a pre-op needle, which means she’s busy only about 30 percent of the time and then goes home at 2 pm. We head back to the OR.

After a few minutes waiting in the OR, the nurse wheels the patient in. I clumsily attach the pulse oximeter, three electrode lead stickers, and blood pressure cuff. I mistakenly attach the “left leg” lead, supposed to go under the left breast, on a layer of gown. “Honey, this isn’t my breast!” I grab another sticker and place it below her breast and attach the electrode. He supervises me closely as I preoxygenate the patient with a mask delivering 100 percent oxygen. He then pushes the propofol into the IV and we wait a few seconds. He instructs, “gently touch her eyebrows to assess if she’s asleep.” The first time her eyelid twitches but after five more seconds she is fully induced. 

“Let’s see how you mask ventilate. This is probably the most important skill in anesthesia. If you can mask a patient you can relax.” I adjust the pressure in the circuit with a knob as I squeeze a 2 L bag with my right hand and use a “C” grip on her mask and jaw to elevate the jaw. “Really squeeze at the angle of her mandible. Get in that crease.” I am squeezing the mask with my thumb and index finger in a “C” shape to rotate it against the jaw that is being pulled up and out to move the tongue forward and open the airway. The first breaths I hear a leak as I squeeze the bag with my other hand, but adjust my grip. I look for chest rise, fog in the mask on exhalation, and finally check the end tidal CO2 mass spectrometer waveform on the anesthesia workstation.

As I mask the patient monitoring the end-tidal CO2, tidal volumes, and peak pressures (keep under 20 mmHg to prevent air from going into the stomach), the attending asks me, “We know we can mask the patient, so we can relax. Why do we pre-oxygenate?” I answer with a snarky response, not understanding the full significance of the question. “Umm, to get more oxygen in them.” He responds with a smile, “Yes, but why does it work?” He explains that at the functional residual capacity (FRC, the amount of air in the lungs when exhaled such as when paralyzed) there is 2 L of air, and therefore 400 mL of oxygen (20 percent at 1 atm). Your body uses about 35 mL oxygen per kg per min, which varies depending on the health of the individual and food intake.” For a typical 70 kg person, that is 35 mL oxygen per second so I would only have about 10 seconds before the patient starts to desaturate if we intubate without preoxygenation. He summarizes, “Pre-oxygenation is really denitrogenation of the air.” Instead of only having 400 mL oxygen, by masking the patient with 100 percent FiO2, the patient now has 2 L of oxygen, allowing for about a minute before the patient begins to desaturate. In reality once you preoxygenate, you have several minutes before you need to worry.” After another few breaths, he states, “You’re ready. Give it a try… Wait. Take your badge off, you don’t want to cause a corneal abrasion. Those hurt more than a kidney stone!” He pushes the Rocuronium, a paralytic agent that will prevent the patient from moving any somatic (voluntary) muscle.

After I transfer my badge, notebook, and pens from the front scrubs pocket into my pants, I grab the Mac blade, scissor the upper and lower teeth with my thumb and index finger to open the jaw, and place the blade in horizontally, avoiding the teeth. My goal is to first locate the right tonsillar pillars, then sweep the tongue with the blade over to the left, and insert the blade deeper until I identify the epiglottis. I struggle to find the epiglottis in this patient, and hand it over to the attending who quickly inserts the tube. “Good technique, that was a hard airway. Better luck next time.” He adds, “Careful when removing the blade. A chipped tooth comes right out of my paycheck. $10,000, no question.” 

I auscultate both lungs (listen with a stethoscope) to confirm good airflow, look for fog in the tube, and confirm end-tidal CO2 for a few breaths. He laughs as he’s already given a few bag breaths and turned on the ventilator setting to pressure control (ventilator mode that delivers volume up to a set amount of airway pressure). “It’s good to do that as a habit, but I saw the tube go through the vocal cords, I see good fog in the tube, and consistent end-tidal CO2. Confidence in medicine is key, especially in surgery. Confidence comes from experience. Now, relax. You’re welcome to grab some breakfast or coffee. We’ll just be sitting here until the case ends.” (In search of a stooI, I wander the OR hallways until an OR nurse guides me to the stash. I lug the stool through the maze of gadgets in the OR suite while trying not to touch anything sterile.)

Dr. D has a dedicated chair. We sit together and look at our phones (no need to wear gloves unless touching the patient) for two hours while occasionally talking about subjects he thinks will be helpful, e.g., his ABCDEFGHI mnemonic for taking over a patient.  Airway (confirm placement of airway), Breathing (look at end-tidal CO2, peak pressures, pulse oxygen saturation, arterial blood gas, if applicable), Circulation (blood pressure and heart rate, EKG), Drips (ensure medications are in, including pain, nausea, etc.), Effluent and Fluids (ensure good urine output and adjust IV fluids accordingly), Heat (don’t forget the Bair Hugger), and Injury (make sure the neck is in a neutral position, the eyes are not in contact with anything, the arms are not under pressure and pronated; he explains to me that the ulnar nerve is the most common injury during anesthesia. A lot of time the surgeon is not present when positioning the patient, he explains this is a bad habit because the surgeon is just as liable for any positioning injury as the anesthesiologist). The surgeon tells us that they are starting to close as he unscrubs and steps out of the room to allow his PA to suture the skin and dress the patient.  

[Editor: “Doctor Says a Device He Invented Poses Risks” (New York Times, December 24, 2010), “Two decades ago, Dr. Augustine, an anesthesiologist in Minnesota, helped pioneer the idea of keeping a patient warm during surgery. Doing so, studies have shown, produces benefits like less bleeding and a faster recovery. Dr. Augustine’s invention, the Bair Hugger, changed surgical practices and made him a fortune. The device, which works like a forced-air heater, carries warmed air through a hose to a special blanket that is draped over a patient. These days, Dr. Augustine asserts that his invention is a danger to surgical patients receiving implant devices like artificial heart valves and joints. The forced air, he says, can spread bacteria associated with hospital-acquired infections. Coincidentally, Dr. Augustine, who no longer has a financial stake in the Bair Hugger, also says he has a safer alternative, a warming device that works more like an electric blanket and does not use forced air.” A twin-size electric blanket is $25 on Amazon in 2020. Why did 3M pay $810 million for a company making this hot air system? Why wouldn’t hospitals just buy blankets from Amazon and throw them out after each surgery? Ordinary blankets are used in the OR, washed, and reused.]

We turn off the anesthesia gas and reverse the rocuronium with sugammadex. The anesthesiologist explains as we wait for the patient to wake up that rocuronium has become the standard paralytic because of this new reversal agent. “It was a brilliant move by the pharmaceutical company. If you don’t use the reversal agent, the patient could feel short of breath and weak for several days.” He adds, “You also don’t want to get that call from a lawyer when the post-op patient has respiratory distress.  ‘Why didn’t you reverse her?'” When the patient starts to move her arms, and cough, I deflate the ETT balloon cuff, and pull the tube out. The anesthesiologist pushes the bed into “steer” mode and carts her off to the post-op recovery room, jumping on the frame and riding the bed around every turn as he waves to the OR staff. I struggle to keep up with him. He backs the patient into the post-op room, and “gives report” to the nurse. We head to pre-op (right next door) to get ready for the next

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Medical School 2020, Year 4, Week 30 (Radiology, week 2)

I ask to focus on abdominal CT during this final week of radiology, which turns me into an expert on finding steatosis (fatty liver, caused by alcohol, viral hepatitis, or obesity). It’s easy to identify because it’s on every abdominal and pelvic CT! Prasanna’s partner explains how to differentiate steatosis from fibrosis/cirrhosis by the liver morphology. CT can differentiate interfaces between air (-1000 Holmzfeld units), fat (-100), water (0), soft tissue (30), and bone (1000). The liver and spleen should be similar densities. As fat infiltrates the hepatocytes, however, the liver density begins to drop below 60. NASH (non-alcoholic steatohepatitis) is expected to surpass alcohol-associated liver failure to become the number one cause of liver transplantation. The radiologist explains, “The liver edge should be smooth. Once fibrosis occurs, it becomes nodular. Cirrhosis is also associated with enlargement of the caudate and left lobe. You can do a ratio, but just eye-ball it.”

The abdominal work list is exploding. The attending yells, “Six scans come off one scanner in one hour. Six abdominal scans. Why couldn’t they have interweaved some lumbar and head CT? Come on! I can do maybe 5 CTs per hour. Six from one scanner, and this seat covers five other scanners. We are just getting slammed.” As soon as he is done venting and has refocused on another case, his phone rings. “Come on!”

We overhear Prasanna yell, “God Dammit.” We walk over to investigate. Prasanna waves me in. “This is the MRI from the hip arthrogram we did earlier today. What do you see?” Based on irregular T2 signals with T1 replacement (bone marrow destruction) and articular cartilage flattening, I answer, “O-N.” Osteonecrosis is bone death, typically due to reduced blood flow. He tries to pull up the X-ray. “They didn’t get a f***ing X-ray. This is why you always get an X-ray first. This could have been diagnosed weeks ago instead of waiting for an MRI. He’s going to lose both hips.” I ask what caused this? “O-N can be caused by lots of things. Osteomyelitis (or infection of the bone) is one, but I don’t think both his joints are infected. It could be from long-term steroid use, inflammatory conditions, congenital abnormalities, and trauma. There’s a whole differential. Sometimes it’s just idiopathic [unknown cause].”

We do a leg bone length study on a 13-year-old. Children who suffer a broken leg can end up with one leg growing dramatically longer than the other. We measured from the top of the femoral head to the top of the talus. “The truth is orthopedists do their own measurements, so I don’t get too technical. Each has his or her own favorite method. Some old school private practice orthopaedists keep their radiographs in-house. I do all this for our health system billing and CYA. They need our help for MRIs and CTs.” Prasanna asks, “What do you think the most common lawsuit is for orthopaedists that keep radiographs in house? … Missing lung cancer on a shoulder X-ray.”

On Friday, I work with a guy who finished radiology training only three years ago. “This seat [MSK] is so boring that it erodes my soul.” He drones “Normal” into PowerScribe after every X-ray, which allows ample time to discuss the coronavirus: “I don’t think people realize what is coming. The virus is reported to have almost a 20 percent infection rate. On the cruise ship, one asymptomatic person infected 600 people. Our health system covers about 1 million people. We have 54 ICU beds. The numbers just don’t work.”

[Editor: This is late February 2020, about two months after the media began intensive coverage of COVID-19. As it happens, the hospital never did run out of ICU beds. The hospital filled up completely in January 2021, but mostly because patients couldn’t be discharged to their nursing homes so long as they tested positive for COVID-19. See “Our hero’s hospital is full (but not with patients who should be there)” in which I noted “Essentially, the hospital is packed because, even with nearly a year to prepare, state and local health departments that regulate hospitals and track hospital capacity couldn’t get organized to turn empty hotels into Covid-19 halfway houses.”]

The junior radiologist continues: “On top of this will be a supply crisis. Our health system reverts back to the medieval age when we don’t have common medications. Penicillin is not made in the US anymore. There is going to be a huge shortage of needles. China supplies everything, and they are shut down.” Is he stockpiling? “Oh yeah.” He grabs another coffee, his fifth today. “Let me get caught up.” He speeds through 10 radiographs in a few minutes, dictating with prefilled phrases. He turns to me. “The three fastest radiologists I have ever seen are all here. The fastest offered to do 1.5 lists and get paid at 1.5 FTE. I can see his point because he could handle it, but it would set a dangerous precedent if all you care about is speed. His offer was rejected, so he started the medical student clerkship. We’re not all as fast as him, so we fall behind when students are here.”

We review a pelvic CT. He laments, “Look at this! Hip pain. It doesn’t specify if the pain is in the hip joint, greater trochanter, or SI joint. No clinical history. I’m so used to it, but this lack of communication hurts the patient. Help me help you! The worst is when we get an abdominal/pelvic CT for ‘abdominal pain, unspecified’.” He continues, “Epic has made this communication crisis worse. The ED doc or PCP just clicks a worthless button and moves on. I can use Epic to read the doctor’s notes, but I shouldn’t need to do that. The MSK seat is not as bad as the abdominal seat as there are far fewer potential diagnoses.”

Statistics for the week… Study: 0 hours. Sleep: 9 hours/night; Fun: 2 nights. Example fun: Dog playdate at a local park followed by a dog-friendly brewery.

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Medical School 2020, Year 4, Week 29 (Radiology, week 1)

A two-week elective in MSK (musculoskeletal) radiology. The private practice radiology group that staffs our health system’s department offers 4 hours per day for medical students. I’ll be working in a large newly constructed clinic building from 9:00 – 11:00 am and 1:00 – 3:00 pm each weekday.

A typical day is as follows: I meet the attending on the MSK seat at 9:00 am. Precise Prasanna, a 39-year-old MSK fellowship-trained radiologist, is walking on the treadmill and dictating a shoulder MRI. He stops the treadmill to chat for a few minutes. Having arrived at 8:00 am, he is caught up on the worklist and has “parked” five interesting cases from this morning. He leaves the room for five minutes to refill his water and chat with his colleague on the abdominal seat while I go through them on the diagnostic monitor screen. 

I report what I have observed: “There is a high T2 signal in the right superior hip labrum.” He replies, “Good, look at the cam deformity [enlarged femoral head knocks into the acetabulum] causing femoral acetabular impingement.” He continues, “FAI is now known to be the most common cause of early osteoarthrosis. We see this all the time in female soccer players. A 10-year-old presents for anterior hip pain from a labrum tear. When you ask them they sometimes report their hip ‘stopping’ but kids get used to the impingement feeling. Twenty years ago we would have forgotten about it; now we realize FAI causes early OA so we intervene before destruction of the cartilage.” FAI can be diagnosed on a simple AP pelvis radiograph.

(Arthritis includes the suffix “itis,” suggesting inflammation, but most arthritis is due to wear and therefore osteoarthrosis is the preferred term.)

He points out the interesting aspects of 20 X-rays and 6 MRIs before it is time for live patients. We do three arthrograms, in which contrast agent is injected into the joint space under X-ray guidance. Most commonly, this is with gadolinium contrast in preparation for an MRI to fully assess the hip or shoulder labrum. Sometimes, this is to get better information from a patient who is not a candidate for an MRI. For example, Prasanna performs a shoulder arthrogram on a 28-year-old female bicycle accident victim whose implanted hardware following a previous humeral head fracture (motor vehicle collision) would distort the signal from susceptibility artifact. He points to the leaking of contrast from the joint space into the subacromial/subdeltoid bursa (fluid-filled cushion underneath tendons), indicating a full-thickness tear of the supraspinatus tendon. 

After lunch with Jane and our new puppy, I return for the 1:00 pm session. The radiologist in the abdominal seat calls me over to look at a CT scan of the chest and abdomen. “What do you see?” I respond, “There is a clear hypointensity disrupting the bright signal of the right pulmonary artery. Is this a pulmonary embolism?” He answers, “Yeah, I just sent her to the hospital. I don’t see any right heart strain. That’s all!”

Prasanna dictates reports with PowerScribe, voice recognition software specific to radiology. Every word he uses serves to further delineate the pathologic process. He explains to me that the main goal of an musculoskeletal radiologist is to pick up subtle findings of a pathologic process, e.g., rheumatoid arthritis, psoriatic arthritis or severe meniscus tears, before it severely damages the articular (hyaline) cartilage. Once destroyed the joint is unsalvageable and must be replaced (arthroplasty). “For some diseases we can stop the inflammation with drugs or for some mechanical injuries an orthopedist can operate and prevent OA. If you see acute, non-traumatic, monoarticular arthritis, treat it as a septic joint until tapped [remove fluid with a needle].”

Every hour with Prasanna is an opportunity to learn more vocabulary, e.g., the Lisfranc ligament, named after the French surgeon who pioneered the “Lisfranc amputation” of the tarsal-metatarsal joint (mid foot) during the early 1800s. I learn names for common injuries from a shoulder dislocation, including the Hill-Sachs lesion (humeral head fracture as it strikes the glenoid) and the commonly accompanying Bankart fracture of the glenoid.

[Editor: read Madame Bovary for some insight into 19th century French foot surgery.]

School administrators had stressed that I was to work only with the MSK seat and stick to the 9-11, 1-3 schedule. On Thursday, however, I asked the two radiologists if it would be okay to work from 9-1, spending half the time with the abdominal seat, and having the whole afternoon free with the puppy. “Of course,” was the answer.

I watch Prasanna perform a hip arthrogram in prep for an MRI on a 59-year-old with worsening anterior hip pain and clicking for 3 months. He weighs at least 300 lbs. Once the needle is in the joint space, straw-color fluid slowly flows out of the catheter. This went on for a few minutes, until Prasanna aspirates a total of 50mL. “That feels so much better,” exclaims the patient. “I’m glad, the pain might come back a bit as I inject the contrast now.” After the procedure, he asks, “Do I need a hip replacement?” The radiologist explains, “We’ll know more once we get the MRI, but from just this X-ray, I see preservation of the joint space so my guess is no. You do have a large joint effusion and at least a labral tear so you might still need surgery, but not a joint replacement.”

The abdominal seat is reading a pelvic MRI on a 49-year-old female for rectal cancer staging. “The most important thing is if the tumor invades the sphincter complex.” The internal and external anal sphincter muscles are highlighted by the clear “intersphincteric fat pad” that is being pushed by the tumor on the posterior lateral side. The radiologist: “This is bad. She is going to probably have to get an APR (abdominal perineal resection, in which they remove the anus and create a colostomy). We’ll see what the rectal surgeons say at tumor board next week.”

We have a CT angiogram of an 86-year-old for an adrenal mass, her fourth in two years, due to an anomaly discovered on a CT scan after a fall. The abdominal radiologist says that the test should never have been ordered. “Leave this woman alone. Adrenal masses are statistically benign in the absence of metastatic disease (e.g., lung cancer). Teleradiologists never have the guts to ignore something out of fear of getting sued so she’s subject to never-ending imaging follow up.” He continues, “It’s weird to say, but I don’t always want the ordering provider to follow every finding in my report. Don’t treat the image, treat the patient. We balance this with the knowledge that this report will be forever cemented into the patient chart for litigation years in the future. We used to call up the ordering provider, or he would come down to us. With teleradiology, the doctors don’t collaborate and each one tries to defend against any possible lawsuit. It’s almost like we are in a game of tug-of-war on who bears legal ownership of a patient. Tag, you’re it! The result is that a patient who lives 4 hours from the nearest MRI machine will be doomed to perpetual follow-up on a statistically benign tumor.”

Statistics for the week… Study: 0 hours. Sleep: 8 hours/night; Fun: 2 nights. Example fun: Jane and I attend an engagement party for Outdoors Oswald, a mountain biker applying to emergency medicine at prestigious institutions. His fiance works for Epic, which allows her to work from home most days. She hopes to end up in New York City, even though “we’ll be broke.” They rented a private downstairs room, but did not order any food for the gathering. About half of the class was invited and consequently the open bar was used to the fullest extent. We left at 1:00 am with several classmates to grab a slice of pizza before Ubering home.

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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.”

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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…”]

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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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