Observing Brain Surgery, or, "I can see it thinking!"

As soon as my classes ended on that specially marked day in my calendar, I headed from school towards the hospital. On the bus, I paged the doctor who had replied affirmatively to my e-mail shadow request, as per his directions. I was lucky to have had case-based learning that morning; our small group tutor was an MD who worked at that hospital and was happy to explain how to page the surgeon, a medical procedure I had not yet been trained in. I paged him, and got no reply, so I called his office and his friendly secretary with the British accent told me that he was in operating room 19, and gave me the extension for the phone in the OR.

After debating in my mind whether or not it was appropriate to actually call the OR, I finally worked up the courage to phone. A very friendly voice answered and after I introduced myself and explained that Dr. Otto had agreed to let me shadow, the voice identified itself as Dr. Otto's resident. "We're in OR 19, come on up." I explained that I had never been to the operating rooms in that hospital before. "Fine, that's no problem, page me when you get here at 35-26104, and we'll get you up here." After I hung up I felt a little embarrassed for being nervous to call, but I was relieved that I had chanced upon a friendly member of the health care profession, and that I had chanced upon him between surgeries.

As per his directions, I paged him from the info desk in the lobby of the hospital, and waited for fifteen minutes. No reply. I knew the OR was on the 4th floor, so I decided to go find it on my own, not bothering to waste my time asking the info desk staff, "How do I get into Operating Room 19?" I assumed that they aren't there to answer such questions for people who seem to be members of the general public, as I probably did.

My decision to search for OR 19 on my own led to what must have been the oddest part of the afternoon for me: one minute I perceived myself looking like a random person off the street wandering through the hospital where I didn't necessarily belong, and the next minute, I was wearing scrubs and a mask, standing in an operating room and looking at a living person's brain.

While I was making my way to the OR, pointed in the right direction once or twice by helpful nurses and hospital staff after explaining who I was and ready to brandish my "this bumbling person is a doctor in training" credentials, I became very appreciative of my extensive experience in operating rooms during my pre-med trip to Nigeria. Had I not learned the rituals and rules of the operating rooms in Nigeria, and had I gone trying to find my way into the OR without this experience, I could very well have busted into the OR after maybe trying to scrub in like I'd seen surgeons do on TV, wearing my street shoes and lacking a hairnet or mask. Fortunately I had been briefed on OR rituals long ago and knew to slip on some shoe covers, put on a surgical cap, and find where they kept the masks, and that observers don't spend five minutes at a sink brushing all surfaces of their hands, fingernails, wrists and forearms. Scrubbing is only for the people lucky enough to be assisting or operating, not observing, and I would not be offered the opportunity to assist my first time watching neurosurgery. This was entirely fine with me, and I assume the patient as well.

When I got into the OR, Dr. Otto, the neurosurgeon was incredibly friendly. He greeted me cheerfully, and after the surgery was well underway he was happy to provide the odd clinical tidbit here and there. "Come look, Vitum, here's the cerebellum... pulsating... as it should." Wow, I thought. I can see it thinking. It wasn't moving rhythmically like a large vessel with blood being pumped through it at regular intervals; instead, it almost looked alive, like a jellyfish or the head of an octopus undulating gently and peacefully within a protective layer of bone that had been chipped away to reveal its hiding place. "What happens to the bone after the surgery? Does it grow back?" I asked. "Nope." I pictured this person recovering with a soft spot in the skin on the back of their head, where they could poke their brain through the skin and muscle using their finger, and presumably affect their balance or other functions associated with the cerebellum.

As interested as I had been in surgery after my time in Nigeria and before observing the brain surgery, I soon became impressed by how bored I was with the procedure. There was a lot of waiting on my part; a lot of meticulous cauterizing (burning) of blood vessels in the process of removing the two tumours, each smaller than a walnut; a lot of slow cutting and bone chipping before that; and a lot of slow sewing after that.

So, to not spend my time craning my neck around the operating doctor and assisting resident and observing clerk (third-year medical student), I spent a fair bit of time chatting with the other members of the health care education hierarchy who were coming in and out of the room. The clerk on rotation in surgery took me over to the X-ray monitors in the corner of the OR, and spent some time explaining the basics of looking over and presenting an X-ray. "First make sure it's the right patient. Then, check the date. Comment on the other things in the X-ray; ECG wires, or chest tubes and the like. Move on to the quality of the film; if you can see the vertebrae distinctly it's a good exposure." He continued on through the art of presenting an X-ray, using a film from a surgical patient from earlier in the day who had developed acute pulmonary edema. I was excited when this condition was mentioned in lecture a few days later, and I already knew what it was from my time shadowing in the OR.

The neurosurgery resident was very chatty and also friendly, as I had experienced on the phone. He told me that a prerequisite of being accepted into the neurosurgery residency is that you have to have a girlfriend before you start, because you sure as hell won't have time to meet a girl while you're a neurosurgery resident. I actually ran into him in the ER when I was shadowing another ER doc a couple weeks after I shadowed brain surgery; at first I knew that I knew him from somewhere but didn't know exactly who he was until shortly after he started talking to me. Honestly, I would probably have recognized him sooner had he been wearing a surgical mask.

Another resident in the room, an Asian doctor who was in a residency in interventional radiology or something of the sort, and she recounted a story of how difficult it is for female doctors to pick up guys. "A friend and I were at a bar, having a great conversation with a cute guy. He asked us what we do, and I replied, 'I'm in medicine.' He asked what specifically, and I replied, 'I'm a doctor.' At that point, he literally turned around 180 degrees and started a conversation with another girl." I told a friend in second year about this. She told me that "we call that the 'M-bomb', telling someone we're in medicine. I get around that by telling potentials that 'I am in science; I'm interested in becoming a doctor someday.' That seems to intimidate a lot less."

The neurosurgeon and I even had a good chat. I was able to pass on a message from someone else in my class, that he had influenced her to enter medicine when he gave a talk to a group of pre-meds she was in a few years back.

I even cracked a joke that made the whole OR laugh; they were talking about how rich the two creators of YouTube must be now that Google had bought their little website for 2 billion dollars. I piped up, "Yeah, but they have to split it..."

I didn't have a conversation with the anesthesiologist, but he successfully perpetuated my stereotype of what anesthesiologists do during surgeries, as he was busy working on a PowerPoint presentation on his iBook laptop computer. That will be added to my anesthesiology stories of members of that profession who do crossword puzzles, sudoku, nap, or perform yoga on a mat in the corner of the OR during surgery. "It's ok if they fall asleep," my medical student friend told me; "their alarms will wake them up if something goes wrong, and the surgeons wake them up if it's time to close."

After standing around chatting for so long, checking up on the previous surgical patient who ended up with pulmonary edema, and coming back to the OR and chatting some more, I decided to call it quits. I said my farewells, and was welcomed by the surgeon to join him again at any time, but I'm not so sure anymore if surgery is for me.

I was told by an anesthesiologist that one way to categorize medical specialties is into two types: those that have you do one thing, finish it, and move on to the next, versus those that handle you juggling several balls at once. Surgery and anaesthesiology would fall under the former. I think I'm leaning more towards the latter. Fortunately I've got lots of time to decide for sure. But, I don't think that brain surgery will be something I find myself doing as a career.

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Milestone: First Dinner Paid For by a Pharmaceutical Company

I went to a Resident's Research night the other night at a fancy business club downtown. I was attracted by the possibility of the free cocktails, the free gourmet dinner, the experience of seeing this fancy club for free, and not one bit by the free research speech in between.

We arrived, suitably conforming to the club's dress code, and were pointed to a conference hall in the public area of the club. I never did get to see the private member's area with the billiards tables and the swimming pool and the brandy and stacks of the Wall Street Journal. Strike 1.

After that, the first thing we noticed is that there was a price list beside the bar. By "Cocktails 6:30 - 7:00" on the invitation, they meant "Cash Bar 6:30 - 7:00." BIG difference. Strike 2.

At the end of the speech, though, which was mostly out of my league (but it kept my attention because the resident spoke so fast) they served a fabulous and delicious three-course dinner with all the wine we could drink. Outstanding. Reset the count; 0 balls, 0 strikes.

And the best part: right before they served it, they told us that a pharmaceutical company was paying for the dinner. I had been wondering how long it would be before I was getting food from the drug companies; my time had come. I have pretty much arrived. (And I don't feel coerced one bit: to be honest, other than mentioning the name once, they did a bad job of making an impression. I can't even remember the name of the drug company. That makes it OK, then, doesn't it?)

It was well worth going just for the (free) dinner, but the best part happened after dinner. Two young psychiatrists came and sat down at the table where I was sitting with about five other first-years from my class. They told us a lot about psychiatry, answered our naïve questions ("Do you have a couch?" - answer: only about 3 shrinks in the entire metropolitan area use couches), and joked around with us, and gave us some great advice.

Before I get to the advice, let me make this clear: I know absolutely nothing about psychiatry, and in fact, in all seriousness, I am a little bit frightened by the thought of being around psychotic patients. Okay, I know that statement is laden with ignorance and so forth. Go ahead and make your judgments... Strike 1, against me... but hear me out:

Despite my ignorance, I am really interested in actually overcoming my ignorance and getting to know what the profession is like (reset the count against me, 0 balls, 0 strikes). I got the doc's contact info and I'm looking forward to shadowing them in the near future to get a handle on what they really do.

All that being said, however, the most valuable part of the entire evening was the advice that the psychiatrists gave us. I'll leave you with that; it should be helpful to anyone trying to figure out what specialty they should enter.

"No matter what fascinates you now, it is going to become routine after you do it day in and day out. So, when you're in a rotation or shadowing, take a close look at the residents in that field, and see if their level of happiness, their lifestyle, the things outside of what they do for work, jive with what you're hoping for in your career. If they don't, then look for another specialty."

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Brain Surgery

Today I watched brain surgery. It was incredible. I'll finish this post later, and tell you all about it.

**Update 6/1/07
The promised post can (finally) be found here.

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"Don't Ask Shit Questions": To FIFE or not to FIFE

Another med school first.

I'm about to tell you about the first time that I was sworn at by a patient.

I've heard patients swearing at doctors before, but never at me. This was a wholly new and wonderful experience and I am taking it as though I have reached new depth in my irreversible spiral of being sucked into the health care profession, complete with its highs and lows, the latter of which can include being sworn at, among other things.

I'm happy to recount this saga. Unfortunately, it does not come without a lengthy, but hopefully entertaining, prologue.

Prologue

In our medical school we're taking a course on how to interview patients. Sure, most of it is common sense, but in the day and age where doctors are taking hits on having poor bedside manner, the logic behind this can be understood. I have seen, and have heard first-hand accounts, of physicians such as a surgeon who would enter a patient's room, remove the surgery bandage, look at the wound, write in the chart, and leave, without so much as a word to the patient. Yeah, these cases are in the minority, but there are enough of them for the medical schools to start teaching doctors how to be compassionate and how to talk to patients and show empathy and feeling.

So, someone somewhere in medical school curriculum development land decided that there were not enough acronyms for med students to remember and separate them from the general public untrained in medical expertise other than through what they see in ER and Grey's Anatomy, and thus invented "FIFE."

The students in my class have taken very dearly to this acronym, and instead of talking about "asking a patient the FIFE questions" or "using FIFE," my classmates have taken towards stating it in terms of "FIFEing the patient." "In this interview I'll be sure to FIFE my patient," I have heard often, or in further abuses of the loose resemblance of the term another word in the English language, some students will say "FIFE your patient! FIFE them until you can't FIFE any more," or "I definitely FIFEd the _ out of my volunteer patient." No disrespect is meant to the patients, just to the dude who thought that "FIFE" would be a safe word to give to young men and women early in their medical training.

Even our faculty tutors sometimes use this term in a way that could possibly be phrased more gently. A medical student at my school was practicing interviewing a volunteer patient in our communication skills class, and called a "time out" because she didn't know what to ask. "Did you FIFE your patient?" the tutor asked. The patient, with a look of surprise and horror on his face, exclaimed, "'FIFE?!' You're going to FIFE me? What do you mean FIFE?!!"

If you don't know what this means, you're probably wondering by now what the heck I'm talking about. You are not alone, and I have chosen to enlighten you. FIFE stands for Feelings & Fears / Ideas & Impressions / Function / Expectations, and are headings for a number of questions that doctors can ask patients about their illness to determine where the patient is coming from.

For example:
F: "Do you have any specific fears or concerns?"
I: "What do you think might be causing this illness?"
F: "How is this illness affecting your daily functioning?"
E: "What are you expecting from this visit to the doctor?"

You get the idea.

Some doctors don't use these guidelines, some doctors do. Some avoid even the idea of it. A girl in my class told me that her clinic preceptor pretty much used "the anti-FIFE" - don't ask any questions about their feelings because there just isn't enough time if we're going to fit in 6 patients per hour.

In some cases, though, the FIFE questions can be very helpful. To demonstrate this, the course directors brought a standardized patient (an actor portraying a patient with an illness) who complained of wheezing and chest tightness. Questioning the class made it clear that we were all ready to assume that proper treatment would be along the lines of doing a lung test and prescribing asthma puffers; however, FIFE produced valuable additional information that would not have been discovered otherwise. The best example came upon asking the E portion of FIFE ("What are you expecting from this visit to the doctor?"). The patient revealed that she knew of friends and family that had suffered from heart conditions, and she wanted a heart test to rule out this possibility. Us budding physicians hadn't considered that the patient might have been hoping for this, so FIFE prevailed and we were all immediately and wholly convinced as to its efficacy and even stopped making fun of it just a little bit.

Saga

With that introduction I can now move in to the saga of my being sworn at.

I was in my third week of Family Practice clinic and was sent to a room to interview a patient. I walked into the room to see a gentleman in his late thirties peering out the window through the blinds. I wasn't sure how to approach this odd situation, so after composing myself I asked, "What are you looking at?"

"My car. I don't want my car to get towed," he said hurriedly.

He turned around to reveal a gentleman in his late thirties, I'm guessing blue collar, with blond spiked hair, an earring, and a large tattoo on his back and neck. He was the type of guy you might see get out of a beat-up pick up truck at a bar to have a few beers, watch a hockey game, and yell at the TV with his buddies.

I respected his implication that time was of the essence so I decided to proceed a bit more quickly, without asking about his family and hobbies and the like. I introduced myself as a medical student and asked if it was okay for me to interview him; he almost cut me off: "Yeah, yeah, do whatever you need to do, that's fine with me."

I proceeded ask him about the chest pain that had brought him in, and the typical questions about how long, how painful, and the like. "It hurts like hell," he said. I asked, "On a scale of 1 to 10, where 10 is the worst pain you ever experienced, how bad is it?" He replied, "Well, I have gout, and that is horrible pain. Compared to that, this would be like a 1. But this hurts like hell." I tried to figure out what that meant while I scribbled notes on my clipboard.

Once I had gotten a good idea of his pain, admittedly a bit flustered that I was thrown off my normal questioning routine by trying to rush the interview, I realized that I was running out of questions.

Without skipping a beat or showing any signs of distress, I immediately resorted to FIFE. I had the good sense to not ask this man about his feelings, and instead asked what he thought was causing the pain.

"My smoking, for sure."

Score one for FIFE.

I reached into my trusty FIFE question kit and carefully selected another question to present to him.

"What do you hope to achieve by coming in today?" I asked.

He stared at me.

"Um," I rephrased, "what are your expectations for this visit to the doctor?"

He looked at me as if I had just grown a third ear.

"I want to know what it is. I want to know what the fuck it is. Make the fucking pain go away."

And then the fateful blow:

"I just want to know what the pain is. Don't ask me any of your shit questions."

"Shit" questions?! I was devastated. I thought I had been armed with the tools of interviewing by my infallible supervisors, and yet here I had gone and agitated a patient to the point of cussing. How dare he call FIFE "shit questions"!!! FIFE had failed me. And it only went downhill from there.

I tried not to look too flustered and tried to wrap up as fast as I could. I asked if he wanted a flu shot, then I asked if he was taking any medications. He mentioned a drug for his gout, then looked at me and said,

"Dr. Milton knows about all my conditions. I've talked with him about all that already. My history is not your fucking business. Do what you need to do with this, and ask me nothing else."

Again trying not to act too flustered, and sensing something less than appreciation for my efforts, I ended the interview, and told him, "You know, I usually come back in with Dr. Milton, but if you prefer the doctor can just see you on his own."

His response was not what I expected.

"Oh, no, no, that's fine, I don't care if you're here."

A bit confused, and a lot flustered, I left and presented the case to the physician quickly, and hoped that this paradoxical patient would stop trying to test my limits. The doctor came in, diagnosed the illness, and wrote down a prescription. As the doctor was finishing up, he told me to take the patient's blood pressure.

I realized I had subconsciously edged my way as far as possible away from this patient and had my back against the wall, and so upon being asked to take his blood pressure I slowly made my way towards this man that I realized I had been distancing myself from.

He didn't make it easy for me, either. As soon as I put the blood pressure cuff on his arm and had inflated it with a single pump...he freaked out. He jumped and pulled his arm away.

"What the hell!?" he shouted.

I was pretty much at my wit's end, and shocked and confused as to why this guy was reacting this way to the very minor pressure that a blood pressure cuff exerts after only one squeeze of the bulb. I looked up at him in surprise.

"Just kidding," he said.

What the heck!? I'm not sure if there was something not right in this patient's head. My classmate suggested he might be bipolar. Either way, he was enough to make me seriously wonder about his sanity.

Postlude

(Any story with a prologue must have a postlude. It's just good Englishing, and I am a huge proponent of doing grammar correct.)

So that was my first experience being sworn at by a patient, and I can probably expect it to happen again. Fortunately, in the grand scheme of cusses that patients can direct towards their health care providers, this was very mild. At least he didn't start swinging at me or anything; heck, he didn't really even swear at me, just around me. And I couldn't wait to tell my interviewing class small-group tutor what the patient had said about FIFE.

I'll definitely be more selective about when I choose to pull out the "shit questions."

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Top 10 list: Things that make me feel like I'm becoming a doctor (as of First Year)

EDIT (11/21): I had to add a number 11. Find it here.

I kindof had to make this list to convince myself that I'm actually in med school. Like I've mentioned before, our first semester is a lot of just basic biology, things I learned in undergrad (biochem, physiology, etc.), so I can't help but feel that I'm still just taking more biology classes. Until I get to third year, where I report to the hospital every day (and on weekends...and I am given evening shifts...And I'm put on call...) it still seems kindof like school, still. Hopefully this changes a bit in January when we start going through the body organ systems, block by block. Until then, I have this list to go by:

10. Got my second issue of the CMAJ today
It always makes me feel like a member of the profession.

9. Calculating IV infusion rates
Finally, there is an applicable use for algebra and natural log calculations. Boy, was I rusty on those for a while, though!

8. Getting my ID tags
I wear these a bit too often, my excuse being because they're on the same retractable carrier as my bus pass. The third-years make fun of me.

7. Being allowed to shadow doctors in the area
It's hard to arrange this when you're a pre-med!! I've already shadowed an ER doc back home, an ER doc here, and going to shadow a surgeon next Monday.

6. Learning how to interview actor patients in my interviewing class

5. Interviewing real patients in the family practice clinic

4. Getting sworn at by a patient in the family practice clinic for asking questions I was told to ask in my interviewing class
I'll definitely tell this story soon!! EDIT (11/20): This post is now available here. (Title will be: "Don't ask shit questions" - To FIFE or not to FIFE. Another time, though; I'm keeping busy and don't have the time right now).

3. Cadaver lab
Partly because I get to wear scrubs, and partly because this was something I envisioned doing when I got to medical school, since not many people get this privilege.

2. Giving injections
This isn't #1 because some of my friends who were in nursing when I took my undergrad were giving injections way before me, so I was jealous of them and when I got to do it I only felt like I was caught up to them.

1. Getting my stethoscope
The excitement of this has started to wear off, but the day I got it I felt like I was pretty much ready to graduate and be called "Doctor". Don't laugh. Small things amuse small minds. And when you pay that much for something, you may as well appreciate it.

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Back in the hospital: ER shadowing

School is great so far, but the general basic biology review that comprises our first term is a bit slow and lacking in clinical experience.

Things will brighten up when I get my stethoscope / otoscope / opthalmascope next Tuesday. Also that day, I start my first of four experiences in a family physician's office, which is going to add an exciting element to my medical education.

The doctor I'll be shadowing seems pretty cool, and excited to have us, which is nice. He sent me an e-mail that got me really excited. Part of that e-mail:

In my office, you will be doing more than just talking. I expect you to do limited physical examinations under my supervision. So yes, bring all your instruments. You will also have a chance to do some minor procedures, like giving shots or taking out sutures. In another word, you have to work. Flu shot season is coming up. Hopefully you will be an expert in giving shots by the time you leave.

I hope you will have a good experience and at the same time, have some fun. Books can be very boring.

That's all you need to tell a med student to get them very excited. As well, his practice is about 60% Chinese, "so polish up your Cantonese." And, I don't have to wear a tie. Nice.

Though I'm required to get that experience, I'm still trying to get some more exposure to the specialties I'm most interested in right now, namely, OR and ER. I finally have had enough of trying to smother my itch for clinical exposure and signed up to shadow an ER doc for a couple hours yesterday. Our school has a comprehensive online list of about 100-150 local docs in all sorts of specialties who are happy to have med students to shadow them, so I looked one up, and yesterday found myself wandering towards the big city hospital a short walk away.

I haven't been orientated to that hospital, or any hospital here for that matter, so I wandered in through the paramedic ER entrance, put on my short lab coat in a hallway and wandered over to meet the doc.

The doc I was following looks EXACTLY like a younger, shorter, blond Greg Kinnear. I kept doing double takes all night. He was great to shadow; it was pretty busy and he also had a R1 (first-year resident) and a MSIII (third-year medical student) following him around, but he was happy to have me there.

It's only the second ER I've ever shadowed in, too, so it was neat comparing the two places. This big city hospital had all sorts of neat stuff: a very belligerent HIV+ homeless individual who got drunk on rubbing alcohol and bumped his head and subsequently cussed out the doctor at full volume when the doc tried to get info about his HIV condition; a lady with alpha-1 antitrypsin, sepsis, lung transplant (alpha1 is one of the few conditions we've actually learned something about so far); a 50-year-old Fijian gentleman who had recently had a SEXTUPLE bypass (never heard of that before)!

It was also my first experience with actual teaching-hospital-attending-doc pimping, something I had only heard about to date in the medical blogosphere. The doc asked me a few medical questions, which I wasn't expecting. Fortunately, one of the ones he asked me (why do we give thiamine when we give glucose?) was something I learned this week in class. He seemed almost surprised that I knew the answer.

I enjoyed seeing what the MSIII does, as well. It'll be exciting to finally be on the floors and doing medicine and interviewing patients and doing procedures. He did a great job of presenting cases to the attending; I wonder how some of the people in my class will end up when it comes time for them to coherently present cases. At this point, at least, they don't seem nearly as confident...or competent...as he was.

[Formerly the first half of a longer post; second half can be found at the post Post-ER-Shadowing Advice]

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