I sterilized a man today.

Sticks and stones may break my bones...

...but you better watch out, because I now know how to do a vasectomy.

Thanks to my nimble fingers, three men limped out of the urology office this morning, their virility forever compromised...at least we hope it is.

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Make sure you know what you are getting into... [part one]

One of the pieces of advice I was given as a pre-med, and that I frequently give to pre-med students (it's #7 on my Top 10 list of advice for pre-med students) is,

"Make sure you know what medicine is like before you sign up for it."

That was ringing quite loudly in my mind when I started my call shift the other night. I had had a busy week in surgery. There were some really long days of showing up on the ward at 7am then a full day of office then going straight to the hospital at 5pm and seeing emergency patients and eventually taking them to the operating room and getting home well into the wee hours of the morning... with a full day in the office after that.


Most of the surgeries were routine, but some came with the emotional stress of having to tell a patient and their family they had a 50% chance of dying on the operating table, and a 50% chance of us opening them up, finding that we could do nothing, and closing them up to face their death within the next few days. (One patient's response to that speech? "Bloody hell." Yeah, no kidding.)

I also had a long academic half-day full of lectures on things that I need to know but had no energy to learn, that also went late into what was going to be my evening relaxation time.

I had to try and fit in studying for my two upcoming exams in between all that, and then on top of that I tried hard to make time to get some exercise and spend some quality time, either on the phone, online or in person, with the people in my life who mean a lot to me. And no, there was no time for going to my buddy's poker game, watching the Leafs get their butts kicked (I haven't watched one game this season!), an afternoon round of golf, or any of the other things I would have enjoyed doing that resemble this "having a life" thing I've heard so much about.


As soon as I finished work in the surgeon's office for the last day of this tough week, I headed to the hospital to get my pager and start call - and within five minutes of my call shift starting, my resident and I had five patients to see, all of whom were pretty sick. Just as we were trying to figure out who to see first, the pager went off two more times. We didn't get a break longer than ten minutes until 2am, when I got a bit of sleep before the pager started going off again (getting a bit of sleep means it was a lucky call night).

I'll admit when all those pages were coming in right at the start of the shift, I was feeling the stress of the whole week on top of having a lot on my plate all at once, and I fell into a rut I find myself in once every year or so when all the negative thoughts come rushing to me. I find myself seriously asking if I am in the right place, if I made the right career decision, if I will ever be able to treat patients on my own, if I really knew that medicine was like this before I invested all that effort and money into pursuing it.


Fortunately, the five minutes the resident gave me before I had to meet up with him on the ward was just enough time to break down, almost re neg on my no-crying policy, and beg for some strength from heaven.

Fortunately, God was listening and obliged. And all in all it ended up being a really good call shift. For me, that means a night with some varied, useful cases that are important for me to learn how to manage, and with some good opportunities for me to see patients on my own, evaluate their situations, and develop a plan and present it to the resident for their approval and questioning. We triaged those first cases well, and got through them and all the other calls throughout the night, and put off studying for just a few more hours in order to do those therapeutic things like write this post and sleep in late for the first time in a while.

::: part two to come... :::

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Valuable principles for my upcoming clinical year

I've heard that on the words, nurses can be your best friend, and your worst enemy.

I have also heard that the more careful attendings, when asked to write a reference letter for you, ask your residents, nurses and other hospital staff about their experiences with you when the attending wasn't around... and you should therefore always act as though your attending is right beside you. Rumors can travel fast in hospitals, especially small ones.

This week I experienced a situation that reinforced both of these points quite well.

I was job shadowing an anaesthesiologist in the OR, and our second-last case of the day was the cutest ten-year-old girl, who charmed the socks off every single person she smiled at. She was such a sweetheart that everyone was disappointed when we had to put her under for her tonsillectomy.

Later on, when we were bringing our last patient into the recovery room, the nurse there came right up to me and took a good look at my ID badge. She then turned to the doctor who was supervising me, and told him, "You should know that your medical student Vitum is outstanding. He came in and checked on that little girl with the tonsillectomy to see if she was awake yet, and I was so impressed with him."

That would probably have really impressed my supervising doctor, had he not known the truth. But he did, and I couldn't take the credit and explained to the nurse: "Thanks, but I was just doing what I was told... the anaesthesiologist asked me to check on the patient!"

While I still believe that sometimes the things you do that go unnoticed are the most rewarding, the reality of medical school is you need those writing your evaluations and reference letters to be able to put down something tangible and positive if you want to to get where you want to go.

So maybe this is a third good principle for me to take with me to the wards in third year: it's sometimes the little things, just as much as the brilliant life-saving interventions, that will impress your supervisors...and more importantly, your patients.

Let me know if you have any more nuggets I should keep in mind next year on the wards!

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SurgeXperiences 107 Blog Carnival

Welcome to SurgeXperiences 107!

On the forefront: Robotic SurgeXperiences

• Aggravated Docsurg talks about what robotic surgery is all about.
  
  
• Once you've read that, another perspective can be found at surgeon's critique of robotic surgery.

Patient and Provider eXperiences

• Bongi tells the story of a surgery hopeful who had an unfortunate experience in the OR. I'd recommend if you read this one, you don't miss the postscript.
  
  
• While it may be minor as far as surgical experiences go, JD had a thyroid nodule biopsy performed recently, and explains the process from the patient's perspective.

Surgical eXperiences Abroad

• Kathryn provides a description of surgery in less than optimal conditions in a less than first-world country: "...The residents even tried to do surgery with sterile drapes wrapped around them because there aren’t any gowns at the moment..."
  
  
• Going to a different country to get surgery or other medical procedures done can be intimidating, but the Medical Tourism Guide provides a how-to guide for Researching a Doctor's Credentials - a must-read for anybody considering getting treatment abroad.

eXperiencing Surgery outside the OR

• If your friends ask you to play "a game of recreational surgery" with them, you may be interested in joining them since that's the name of a board game. I'd suggest you politely decline if any of your med student friends ask you the same thing, however.
  
  
• If you prefer a surgical game of the online variety, take a look at simulated Open Heart surgery.
  
  
• When I was a kid, I thought "plastic surgery" was akin to a game and had something to do with fixing people using doll parts. How fortuitious I corrected this bad impression by reading this excellent description of plastic surgery, lest I bring a Barbie to my first plastics elective in an attempted show of preparedness.

That's all there is to eXperience in this edition!

Special thanks to Jeff from SurgeXperiences for asking me to host this edition! Next week's can be found at Aggravated DocSurg on November 11.

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The Official Grand Rounds, Volume 3, Number 43

Welcome to Grand Rounds, Volume 3.43, hosted for the first time ever at VitumMedicinus.com.

Having used Grand Rounds as a springboard into the world of medical blogging when I first started reading medblogs, it is truly an honour to be hosting Grand Rounds.

The template for this Grand Rounds is as follows:

Description: In his quest to bring you Grand Rounds, Vitum Medicinus went from excitement to panic to enjoyment. Excitement = signing up for Grand Rounds months ago. Panic = when 22 submissions had arrived in my inbox by Friday morning. Enjoyment = putting GR together. Once I got started, it was actually nothing to be panicked about.
Why you should read it: There are some stellar posts in this edition, and for every post I’ve spelled out why it’s worth your time. As well, for the bloggers observant enough to notice that I requested they submit their favourite food along with their blog post, you’ll notice their dish of choice represented pictorially beside their entry. Just one more way Vitum Medicinus is going above and beyond in an utterly pointless and time-ineffective manner.
Award: Grand Rounds 3.43 gets the Vitum Inclusivus award, for subscribing to the age-old (and very childish) “Everybody Wins” concept. This has been manifested in the following manner: Each of the 35 blog posts that were submitted and received a confirmation e-mail have been included, and every one has also received a cryptic Latin-ish award of some sort. (If you need a certificate of your award for your office or bedroom, for reasons of ego-bolstering or personal gratification, you are welcome to print one for yourself.)

Please enjoy Grand Rounds volume 3.43. Feedback, discussion, and criticism of this edition of Grand Rounds are requested and are very much welcome.




It’s pretty annoying to have to deal with a spoiled kid who says “I’m telling my dad!” when they don’t get what they want. Val Jones, MD at RevolutionHealth.com writes about a young man with VIP syndrome, who does just that, and complains to his dad that he wasn’t admitted when there was no medical indication that he should have been. This guy treats the hospital like it’s a casino – at the end, he expects that his care should be comped because his dad threw a lot of money into it. (This would rarely happen in Canada, by the way.)
Why you should read it: You’ll be disappointed to read how elaborate this becomes, involving the CEO of the hospital and the patient’s insurance company… especially when you find out who gets the shaft at the end. As well, you might be interested reading or contributing to the discussion generated by this post.
Award: The Geographicus relocaticis award, for rightly putting this arrogant, snotty, spoiled brat in his place; as well, placement in Vitum’s Top V.

If somebody tells you that after this year’s Running of the Bulls, they have “reviewed with interest the reports and video clips of the bulls goring the runners,” they are either a) a bit out to lunch or b) a surgeon. Having not done clerkship, I have no bitterness towards surgeons (yet?) so I will not take the well-set-up opportunity to say something like “you have to be ‘a’ to be ‘b’.” Won’t go there.
Instead, I will simply say that the editors at Inside Surgery have put together a unique post they call “Possible Types of Injury after being Gored by a Bull.” I don’t think any more explanation is necessary. Strangely enough, this submission is eerily similar to my medschool friend’s desire today to discuss “Possible Types of Injury after being Beaten with a Hammer” (he came up with two thanks to his ER shadowing shift last night).
Why you should read it: Because you don’t want to be in the situation, inevitably someday, when you wish you did. Read it, and then you’ll be the hero who knows what to do when you’ll have to provide first aid to / assess / refer a patient who has been gored by a bull. Subsequently, eligible members of the opposite gender will flock towards you. (Not guaranteed.)
Award: The Practicalus improbabalus award, for being practical advice for an unlikely situation; as well, placement in Vitum’s Top V.

Maria at Intueri.org hosts a Literary Medblogging Project called A Picture is Worth A Thousand Words. The writing in this little project is so good that I can’t even top the description that Maria submitted: “Five medbloggers of the more literary persuasion collaborated on what has become an (at least) annual event--you know, to take a break from the usual randomized, double-blind, placebo-controlled rants that usually occupy our blogs.”
Why you should read it: Stunning writing. Times five.
Award: Serialus excellencissimus award, for high-quality writing over and over; as well, placement in Vitum’s Top V.

In an old man’s final hours, a nurse came into his room with a syringe and hooked it up to his IV. When the patient’s son asked what she was administering, she said, “Oh, just some morphine. Just to make him comfortable. We don’t want him in any pain.” It wasn’t long after that my grandfather breathed his last.
Geena at Code Blog submitted a story that reminded me a lot about this incident with my grandfather, and her and I actually got into a little bit of a discussion about this practice that happens in real life but isn’t taught in nursing school. In her post “On the verge of what society finds acceptable,” she reacts to a physician in the UK who took this one step further, administering not a sedative but a paralytic to an infant with agonal respirations.
Why you should read it: You should know where you stand on topics like this one. If it happened to my grandfather, it could happen to yours, or to your child, or to you. And if doctors are apparently taking this one step further, you might want to know about it.
Award: The Contemplatus arresticus award, for discussing something that goes on in the hospital that makes you really stop and think for a minute; as well, placement in Vitum’s Top V.

Over my med body!'s Graham Walker gets top points for putting together ... get this ... The Clerkship Video Workout Guide, specifically targeted at preclinical students who are about to enter the world of the wards. This video answers a lot of my questions about clerkship, especially the burning one, "What physical manoeuvers can I practice to prepare for my clerkship?" My favourite exercise: "Surgery Exercise Number 1: I like to call it... Just stand there." It's almost as good as the final surgery exercise. Anyone who will one day hold (or has held) a retractor at an uncomfortable and awkward angle will identify quite well with this video.
Why you should read it: Because it’s not even a blog post that you have to read; it’s one you watch. And laugh at.
Award: The Goldenglobus Oscarifficus award, for putting his dashing likeness on camera; as well, placement in Vitum’s Top V.


"A patient refuses a life-saving treatment. What do you do?" Virtually every medical student has looked over ethical cases in an effort to prepare for their medical school interviews. This is all well and good, until you realize that an ethical situation takes on a whole different meaning from reading about it in a book, to when you're on the wards and it's a patient staring you in the face. Sid Schwab writes a post at Surgeonsblog called "Blood Oath" on one of the classic med school interview ethical cases... and talks about how in real life, finding the edges of the often blurry ethical 'line' can be a lot harder than citing a textbook on ethics - or simply falling back on legal precedent.
Why you should read it: Instead of reading about an ethical dilemma discussed by a philosopher sitting in an office, try reading about an ethical dilemma by a physician who has had to put ethics into action in a life-or-death situation. Trust me, it's much more compelling.
Award: Honorarius medicinus, for having the honour to respect patient's wishes, even when some ethicists would say he's wrong, and when colleagues have said they won't do it. As well, a placement in Vitum's Top V (which I suppose is now the top VI) as a way to apologize for my oversight in not including his post in Grand Rounds from the start.


Bongi, the surgeon who writes at Other Things Amanzi, submitted two equally disgusting stories of experiences in the operating room. If you think the job of Grand Rounds editor is easy, it is making decisions like this which choosing between these two posts that would convince you otherwise. I went with the one that doesn’t have the high likelihood of ruining a popular food for you…(medicine tends to do that with food…check back here soon for a post on that, in the works) though I’m sure you’ll easily be able to find the post I chose not to include, if you look for it.
Why you should read it: To prove to yourself that you have a strong stomach, and to catch a glimpse of just how big that mythical creature known as the Ego of Surgeons actually is.
Award: The Incitus Vomitus award for the most disgusting post to Grand Rounds this week. (I won’t translate the name of this award into English. If you really want to know, look it up in any reputable Latin textbook).

It’s a medical student’s greatest dream come true. They are standing in the wards, when, all of a sudden, “CODE BLUE” comes squaking out of the intercom. All of a sudden, the student gets to witness one of medicine’s greatest orchestrated lifesaving ballets in action: running a code. After reading about CODE RED at Rickety Contrivances of Doing Good, I found out that a CODE RED is just like a CODE BLUE - the only difference is, in a code red, nobody knows what to do. Random fact: “Paging Dr. Pyro” is used by some hospitals to mean “Code Red,” according to the infallible Wikipedia. As a patient, I’m not sure which would be more unsettling to hear over the intercom.
Why you should read it: Because experiencing a real live Code Red, albeit vicariously, is pretty exciting (at first).
Award: The Combusticus avoidicus award, for averting certain disaster by fire.

From Counting Sheep, Tales from the Nurse Anaesthesia Front comes a story of a combative nurse who wrestles a patient into TKO, despite the patient being the greatest heavyweight boxing champion of all time. Pretty macho for someone who claims that their favourite food is “any kind of chocolate cake with a warm molten center.”
Why you should read it: This story has to be read to be believed.
Award: The World Heavyweight Boxing Championship Trophy. For obvious reasons.

A post from Musings of a Distractible Mind called “Joi de vivre” talks about how life and work can really get to you. “Life often seems like a hamster wheel - the harder you run, the more tired you get, but you never get ahead,” writes Dr. Rob – sound familiar?
Why you should read it: Because that’s not the end of the story; Dr. Rob has found “a ray of sunshine” to light up the dreary days, and you should read to find out what it is.
Award: Employerus exemplari, for making “Equal Opportunity Employer” more than just an empty statement stamped on his office’s want ads.

In a post titled simply “Loss,” Neonatal Doc writes an incredibly touching story that outlines one of the most tragic moments in any parent’s life – the loss of a child. It’s a moment that admittedly neither a fresh medical student like myself, nor a seasoned physician like neonatologist looks forward to.
Why you should read it: Because it is better to be in a situation of consoling grief once you have read a post like this, which (along with its reader comments) tells you what you should and should not do in that situation.
Award: Lacrimarum nostrum, the tear-jerker award, for making us cry. Have a tissue handy.

Just as in the previous post, the McCanns are suffering from a lost child, but in another, entirely different and equally devastating, manner – their daughter simply disappeared, victim to abduction. Dr. Rima Bishara at The Doctor Blogger has passed on what was originally an e-mail the family hopes will be forwarded extensively so that this four-year-old girl can be found. (Of course, should you choose to donate money to any cause online, make sure that you are looking at a legitimate website - some pathetic criminals have tried to profit from this family’s loss, defrauding people into giving to fake funds by setting up fake websites).
Why you should read it: Because Madeline has such a unique birthmark that unlike many other missing children’s photos, you won’t forget her’s.
Award: Compassionatus empathaticus, for showing the compassion and empathy characteristic of an excellent physician by petitioning for this child’s speedy return to her family.

Bruce Campbell, MD writes a reflection on the difference between “knowing” and “understanding,” as he was taught by a five-year-old boy. Let’s just say that it happened on the 5th of July, many years ago, and like a good dramatic story, this one contains a good dose of suspense.
Why you should read it: Generally, any time a story starts with “This is something I have never forgotten,” it’s usually a pretty good story. As well, this post was designated by a reader as a piece of wisdom worth saving for her unborn grandchild.
Award: The Paternalis aureus award, for providing golden, fatherly medical advice in the form of high-quality writing.

Dean Moyer describes himself as “a guy who discovered one day that he had a bad back and then spent 10 years ignorantly seeking chiropractic treatment for it.” And yet, for an anti-chiropractic blog, it’s actually really well put together and respectable – arguments are objective, the website takes a tone of contemplative disappointment rather than ignorant rage, and he’s not trying to sell quack creams or potions. As you might expect, there are people who take offence to his website, particularly people who stand something to lose should the chiropractic profession be challenged. The post “Dumb Day and Disk Decompression of Delaware” talks about the unusual response of one of these people to Dean’s website. Make sure you click through the “Continuing Saga” links at the end of the post to get the full story.
Why you should read it: A few reasons: 1. The alliteration in the title of his post. It’s incredibly impressive, in its intelligent idiosyncrasies (I spent more time on that sentence than I did on all of Grand Rounds). 2. Hillbilly humour. Always gets a laugh (what I like to call a ‘universal punchline,’ kindof like Chuck Norris jokes). 3. In all seriousness - you might be surprised at the way these “professionals” have responded to Dean’s website when you get to Part 3.
Award: A Bloggisimus novicus award, for being a First-time submitter to Grand Rounds! Welcome Dean!

ERnursey at, uh, ERNursey writes a post just like the ones that got me hooked on medical blogging, called “Dumb reasons to come to the ER.” I don’t know why I get such a kick out of patients demonstrating lapse in judgement, when they’ll inevitably be a source of major frustration to me once I actually become a doctor.
Why you should read it: Because you won’t believe how dumb some of these people are, and because you should leave a comment encouraging ERnursey to provide more stories like this.
Award: Toothicus clenchicus award. For being able to clench her teeth and get through having to deal with these stupid, stupid patients.

“Suffer the children who don’t fit the mould,” by nurse Sandy Szwarc at Junk Food Science, is another one of those posts best described by the author. It begins: “Imagine having a daughter with a rare condition that is poorly understood and health authorities seem disinterested in helping to diagnose. It’s not that girls and boys just like your daughter haven’t been seen throughout history, but today she’s mocked and viewed as a freak and everyone is pointing the blame at you — so much so, that government officials have taken your daughter away and made her a ward of the state.”
Why you should read it: Because you’ll be shocked to read the ridiculous reason this girl was taken away from her family. And, Sandy uses rational discussion to propose that a dramatic blanket crackdown on childhood obesity may NOT be that well thought out.
Award: The Advocatius familii award, for using her background in clinical medicine and scientific education to advocate for the unfortunate parents.

Dr. Linda Regan, a contributor for the NY Emergency Medicine blog, discusses some of her experiences as a female physician ranging from breast feeding to ordering morphine that suggest gender disparities still exist in the world of medicine.
Why you should read it: Because when you read the first story of how she was treated by a chief, you’ll be shocked that things like this actually happen in real life.
Award: The Feminatus commendibus award, for being a female having to put up with what is, in many ways, a male-dominated profession.

Dr. Paul Auerbach talks about a trap that caught his friend during a camping trip. You will be surprised to see how dangerous such simple consumer products can be.
Why you should read it: Because pictures tell a thousand words, and you should click the link lest ye end up in the same trap.
Award: Solutionatus ingenious award, for coming up with more than one possible solution for an unexpected problem. . . and choosing the better one.

When I put out a call for posts containing drama, action, OR humour, I never expected to get a post that tried so hard to fit all three (and did so successfully). Interestingly enough, it doesn’t seem like Kim at Emergiblog had to try so hard – she was treated to all three elements during a shift on her 50th birthday.
Why you should read it: Because a) you need to click on the link so that you can comment and wish Kim a happy 50th birthday, and b) because once you read this you will be convinced to take off work any birthday of yours that ends with a zero (or two).
Award: Kim basically begged for an award, so she gets the Desperatus inclusivus award, for working hardest to fit the theme of this week’s Grand Rounds. You’re one in a million, Kim. (well, one in 35.) Look, you even got your own category!

At first I misread the e-mail and thought that a ham and cheese sandwich was Anonymous Therapist's (Keep Breathing) favourite food, but later realized that a ham and cheese sandwich is instead an integral part of the plot for The Tale of Mr. Bignose, one of AT’s favourite patients.
Why you should read it: Uses a ham and cheese sandwich as a plot device, as well as the word “curmudgeon.” And stories about favourite patients are always worth reading.
Award: The Keenerificus maximus award, for being the first blogger to submit a post to Grand Rounds v3.43.

Written from a patient’s perspective, Ileana’s blog Beating Social Anxiety holds more than one post about feeling like a medical condition rather than a person. In this particular post, “Are you ready to use props,” Ileana tells about a medical student who leaves a much better impression than either the doctor or a resident. (If this ever happens to you, make sure you encourage the medical student. They can always use some positive reinforcement.)
Why you should read it: Anyone in the health care profession should always jump on any chance to see how things are viewed from the patient’s perspective, especially when we need to learn from another health care provider’s screwup. This post is also a solid reminder that you never know if something deeper is going on.
Award: The Bloggisimus novicus award, for being a First-time submitter to Grand Rounds! Welcome Ileana!

Kristie McNealy, MD of NICU 101 tells the story that explains why she would put a residency on hold, and instead focus on family-centered care to advocate for families of premature and critically ill newborns. Unfortunately, it’s another rude healthcare provider story. Fortunately, Dr. McNealy chooses the positive way out, instead of brooding in anger and resentment, she actually uses it to motivate her into making a difference.
Why you should read it: Because this post uses a touching story to show that in the same way that it is important to see things from a patient’s perspective, healthcare providers need to learn to see things from the family’s perspective as well.
Award: Transformus Obstacalis Opportunisticus, the Transforming Obstacles into Opportunities award, for being treated rudely by a doctor . . . and working hard towards making something positive come out of it.


Type I diabetic Kerri Morrone at Six Until Me reviews a highly technical product that promises to revolutionize the medical industry. The only dilemma it presents is whether to use the product when your blood sugar is low, or not.
Why you should read it: Because this product could change your life, and I’m not going to tell you what it is. It even lights up. Personally, I can’t wait to get my hands on one.
Award: Jealousum incitum, for inciting jealousy in me. Yes. This product is that good.

The FDA issued a warning in 2004, stating that antidepressant use in patients less 25 years old can increase suicide rates, after hearing anecdotal evidence from mothers who had lost their children to suicide and implicated their children’s medication. Jake Young at Pure Pedantry lashes out against the FDA for this “black box” warning, citing a recent publication in the American Journal of Psychiatry which wields evidence to contradict the FDA’s anecdotal conclusion.
Why you should read it: Because this issue is a hot topic, and you should get involved in – or at least take a look at – the already hot discussion going on in the comments section under Jake’s post.
Award: Thermophilus symposius, for inciting the most heated discussion topic of any post in this issue of Grand Rounds.

Dr. Jolie Bookspan, also known as The Fitness Fixer, talks a bit about her past research with the Navy. Apparently, Viagra has been tested for use against altitude sickness. Grand Rounds was almost left incomplete as I spent most of the weekend trying to find out how to apply to the navy.
Why you should read it: Because you want to know, just like I did, what role Viagra could play in air travel. (Get your mind out of the gutter.)
Award: The Aviatus Erectus award, for encouraging flight medicine researchers who walk uprightly in both posture and morality. (You! Mind…gutter…out….now.)

Amy at Diabetes Mine has submitted a post called “Help Cure MI,” in which she reviews MI – a condition described as invisible, chronic, and suffered in silence by millions. You might even have it and not know it yet.
Why you should read it: Because you don’t know what either MI or the award below mean, and reading this post will let you find out both.
Award: Paedis ravinus honourificus, or the Crow’s Foot Badge of Honour.

Alvaro at The Sharp Brains blog presents an interview with a paediatrician, discussing a cognitive skill called Working Memory. There are some good examples that help explain what Working Memory is, and how it has helped patients with seemingly insurmountable challenges due to ADD / ADHD.
Why you should read it: Brains are fascinating, and everyone wants a sharp brain. Where better to start than reading a website called Sharp Brains. And it’s exciting to learn of a technique to help children who suffer from ADHD.
Award: The Intellectus stimulatus award, for provision of brain teasers elsewhere on the website. I’ll admit, I got sidetracked.

Mousetrapper at Med Journal Watch describes the latest in Type II Diabetes research: The practice of taking selenium to prevent diabetes has been disputed, with reports in the mass media that it actually can cause a 50% increase in diabetes risk.
Why you should read it: So you can see Mousetrapper’s level-headed recommendation on how to handle this latest perspective.
Award: Cuttimus edgimus award, for staying on the cutting edge of medical research.

Your mother had breast cancer. So did her sister, and your two sisters have both been diagnosed in the last year. What’s the reasonable thing to do? Get genetically tested for breast cancer. Or is it? Dr. Lei writes at eyeondna.com about public perception of genetic testing, and – get this – a recent article published in NEJM suggesting that BRCA mutation carriers with breast cancer actually don’t have a worse prognosis.
Why you should read it: Because Dr. Lei addresses the question, “Given the above, should you still undergo genetic testing?”
Award: Advicum practicalus, for providing practical advice on a topic that can be pretty confusing for medical students, let alone patients.

My mother taught me not to sign my organ donor card. “You never know,” she said, “maybe if they need the organs they’ll let you die, then scoop them up.” TC, an organ procurement transplant coordinator who writes at Donorcycle, tells why this kind of view is more of a myth than anything.
In case you’re wondering, I did sign my donor card. This, by the way, was one of the first times I went against my mother’s wishes, and it has become progressively easier since then – I have now come so far as owning my own motorcycle (okay, just kidding. I’m only at about staying awake past 8:00 pm) .
Why you should read it: Because it’s up to you to decide if TC’s argument should be believed…especially with a title like “Organ procurement transplant coordinator.” (Just kidding. I believe it.) It might also help answer that question which is undoubtedly in your mind, “When I am around an organ procurement transplant coordinator, should I keep a careful hold on my organs?”
Award: The Scooper Dooper award, for being an organ procurement transplant coordinator.

Do doctors owe anything to their patients if they write a book? Even if the book doesn’t include that patient? Or if it does include the patient but alters all details? What about the above scenarios in relation to blogging? LMF, the author at Ad Libitum, tackles these questions in a post entitled “From Hippocrates to HIPAA” in which the subject of blogging about patients comes up yet again. Included is a helpful list of recommendations for medbloggers.
Why you should read it: Because if you are a patient, or a blogger, it is in your best interest to be fully aware of the privacy issues that are paramount to blogging health care providers, and it’s hard to get to the point where you’ve read too many reminders about HIPAA.
Award: The Checkissimus realitus award, for providing a reality check for anyone who runs a blog and reminding us all that we must be accountable for what ends up being published.

Bob Vineyard publishes a post at Insureblog akin to playing “taps” in memory of Dekalb General Hospital’s emergency room. This shutdown is putting the residents in its area an additional 20 minutes away from the nearest trauma centre
Why you should read it: So you can find out why it closed; and, so you can read if an ER near you could be next on the chopping block – Bob lists some other ERs that are within reach of the axe.
Award: Elevatus routus (the High Road award), for taking the effort to actually propose a solution to a healthcare crisis, rather than simply complain about it.

David Williams hosts an interview at MedTripInfo (a blog about international medical travel) with Stephanie Sulger, a nurse and founder of Medical Tours International. MTI organizes trips for patients to receive medical care in other countries, safely and cost effectively. (Unfortunately, due to Canada’s waitlist issue – don’t believe how Canada was painted in Sicko - this is a business that would do well in Canada).
Why you should read it: Very interesting reading, especially the discussion about how Stephanie’s company decides if a hospital is a “top hospital” worth sending patients to or not, or what it’s like suing a doctor overseas, or how some patients are retaining a primary care physician overseas.
Award: The Contemplatis exterioris award, for a solid interview with someone who is thinking outside the box when it comes to getting your health needs addressed.

At Hope for Pandora, Thomas writes about the upcoming confirmation hearings for America’s Next Top Doctor. Thomas suggests that the previous Surgeon General was muzzled by the Bush administration on a couple of controversial topics.
Why you should read it: This is one dramatic, conspiracy-esque plot. Sounds like an episode straight out of The West Wing.
Award: The Artistico award, for having great taste in Blogger themes.

Just when you think that health policy in a state is taking a step in a positive direction in terms of reducing costs, what would expect to happen next? A complete 180° in policy, of course, and costs go up instead of down. Go figure. David Williams writes at the Health Business Blog about one more aspect of the sad health care system those Americans have. (This probably wouldn’t ever happen in Canada, by the way.)
Why you should read it: This could affect you, if you have a health plan through your company.
Award: Flagicus rougeicus, or the Red Flag award, for drawing attention to another concerning aspect of American health care.

A post from Medopedia discusses Pediatric Sibling Transplants, Ethics and Futility in a way that really makes you believe there could be is some reason in trying medical treatments that have been deemed futile in the past.
Why you should read it: Because this post could really make you look differently at the ethics of so-called futile procedures.
Award: Perspectivus broadendii, for having the potential to broaden your perspective on the ethical considerations about futility of medical treatments.

And that’s a wrap! Thank you for reading Grand Rounds Volume 3.43.

Again, feedback, discussion, and criticism of this edition of Grand Rounds are requested and are very much welcome.

Of course, thanks to Nicholas Genes for starting this fabulous tradition. Here's the schedule for the rest of the upcoming Grand Rounds.

Grand Rounds Volume 3.44 will be hosted on July 24, 2007 by Laurie Edwards at A Chronic Dose - click here for the submission guidelines.

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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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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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