Surgery Makes Me Sleepy

I originally wrote this back in January, but I present it here with additional comment.

And by that I mean the rotations themselves, not the experience of being in OR. Though watching residents close abdominal incisions for the 12th time is not the most stimulating experience. Getting up at 5:30 daily - as I have been now since last Monday thanks to the Friday/Sunday call monster - requires early bedtimes, something I've managed to get used to. Today I zonked out about 9:30/10 in the morning and woke up suddenly at 11:27. Remarkably I was only about 10 minutes late to meet a friend for lunch at 11:30. But such free time is so rare these days.

*****

I'm not sure why I didn't finish this post, but it was - likely - a matter of time. Or lack thereof. I've enjoyed all of my rotations since the new year began. General surgery was a lot of fun and very, very busy. My evaluation went really well and it remains a serious consideration for me. I enjoyed neurosurgery less - some very interesting cases and a couple great times getting to be first assist in the OR - but the lifestyle is probably among the worst of any specialty and the residents are overworked. I enjoyed working with the staff, though.

Emergency medicine was a good rotation. I did it at a smaller regional hospital with much more limited specialist support. Saw a large variety of patients and presentations, practised some useful skills (LP, more IVs, suturing, reduction of fractures, incision and drainage, MSK exam), and generally learned a lot. In the end, though, I didn't really like it. There's no rhythm to each shift. You just see patient after patient, many of whom don't require further tests or treatment, determining their "disposition" and making that crucial admit or discharge decision. Not much follow-up. Not enough complexity. At least for me.

I started plastics this week and I'm impressed daily by how well organized the rotation is. Lots of formal teaching and ample experience working in fast paced clinics. I can't complain about the amount of OR time either, even though I'm not getting a lot of skills practice there. Fair to say that I like everything about the rotation. I have been interested in plastics in the past - not really sure I still am. It's very interesting, of course, but the competition to get a residency spot is pretty intense and I probably would miss the medicine available in something like gen surg or, of course, internal medicine.

I suppose that leads to what kind of career I'm considering. That can be left for another post though.

Winter is coming...

Or, since it was -6 today, it's already here. No snow to speak of though. I've now finished one-quarter of my mandatory clerkship rotations. Only surgery, emergency medicine, family medicine, psychiatry, and internal medicine to go over the next 40 weeks. Yay. I did really enjoy obs/gyn, though, and there is something remarkably satisfying about being involved during what is generally a very happy time for parents and families.

Otherwise exams are done and I have a bit of a reprieve to contemplate the Big Questions about career choices and such. I've enjoyed peds and obs/gyn, prefer more acuity and more "interesting" cases, and I like patient care. I don't really see myself going into peds - the inpatient work is interesting, but general peds clinics are a lot of reassurance and issues like ADHD and constipation. Obs/gyn is another matter - I hadn't really thought of it as a surgical specialty as such before, but it certainly is. Gyne problems aren't especially interesting - but the oncology is - and obs is attractive for the reasons above. Still, it may be a bit too specialized...

In the end, it's still down to a more "medicine approach" to surgery (i.e. general surgery) or a more "surgical approach" to internal medicine (i.e. GI or cardiology). Neuro gets thrown into the mix too; even though it's historically been one of the least interventional specialties, it's changing rapidly. We shall see. For surgery, the real issue is the extent to which I can manage the early mornings over a long term. It sounds simplistic - I can certainly get up okay - but taking on such a daily schedule is five years of residency is something to consider carefully. Oh well. I managed fine when on gyne, and it will probably be the same come January.

On verra...

One more week of Peds...

Some things I've learned whilst doing my pediatrics rotation:

• You can never write too many notes.
  
• There's always something you will forget to do or ask on history.
  
• The kids *are* cute, but don't go sticking the otoscope in their ears at the beginning of the exam.
  
• ++social issues
  
• It's spelled "paediatrics" in New Brunswick.
  
• Lectures via teleconference are of variable usefulness. We like the mute button though.
  
• You will sleep at least a bit while on call.
  
• You get used to taking first call quickly. Just call the staff.
  
• Residents enjoy giving advice.
  
• Late night grilled cheese (on whole wheat of course) is the best part of call shifts.
  
• Clinics are sometimes interesting, but the floor is always better.
  
• Nurses make excellent conversationalists day and night.
  
• Handover is the most important part of the day... especially when you're handing over to yourself, or would be if you weren't post-call.
  
• The "post-call" day can still keep you at the hospital til 5. That's afternoon teaching for you.
  
• Code White announcements occur with alarming frequency. You will have come close to calling one.
  
• The parents range from wonderful and congenial to... not so much. They are stressed and worried, though.
  
• Normal babies spit up a lot.
  
• A baby is always better heard crying than not.
  
• Taking initiative is encouraged and welcome but may not be noticed.
  
• There are lots of constipated kids out there.
  
• Call room beds are extremely uncomfortable.
  
• Scrubs are extremely comfortable. And wearing them all day makes up for having no effective post-call day.
  
• NICU is a weird place. Especially since many of the babies don't have names chosen.
  
• The staff are nice. So is Journal Club.
  
• You may technically work as much as 100 hours one or two weeks of a six week rotation. Usually not nearly that bad.
  
• An online system which includes orders and vitals is sublime. It will be missed.
  
• Lastly, you will never want for homemade baked goods, candy, chocolates, or popcorn while working on the floor.
  
• Oh, and boil water orders are annoying.
  

Clerkship is great

We'll see how I feel after Fri/Sun call this weekend. And now a semi-random clip from Scrubs featuring everyone's favourite internist:

Last Post on the "Liberation" Treatment

Well, hopefully. I'm listening to this, an interview with an MS patient who underwent (I assume) balloon venoplasty in Bulgaria. He notes "gradual improvement", but his own descriptions of his symptoms do not sound entirely dramatic. Or notable at all really. The patient correctly notes that current studies underway aim to determine whether, in the first place, MS patients have "blocked" veins and whether there is an association between such "blockages" and MS. Since the so-called liberation treatment in principle treats such blockages, it seems, a priori, that determining the presence of such blockages and their association with MS is, ya know, paramount. You don't treat a "blockage" that has no clinical consequence and you don't treat someone for a blockage that they don't have. A patient with chest pain doesn't go straight to the cath lab.

I've also noticed something curious about most of the anecdotal reports of symptomatic improvement following (or even during!) the procedure; patients seem to report increased ease of movement, which improves with increased activity to some degree. I even came across a blog a while ago detailing a patient's course while following a physiotherapy regime post-procedure. On one hand, it seems clear that the "liberation" treatment conveys a significant positive placebo effect, to the point that patients report instant improvement on the OR table - which itself is as clear a sign as any that the procedure has no intrinsic therapeutic effect (repair of MS-damaged white matter on such an instant basis isn't just implausible, it's impossible). Conversely, it seems that patients see some improvement with increased activity and/or direct participation in physio, which is not altogether unexpected. If there are to be any trials of the "liberation" treatment, I think it would be prudent to control for such factors or even to include physio as a treatment itself. I'd bet money that patients attending and participating in regular physiotherapy do better on several functional outcomes than those who don't (controlling for MS progression variables), and that any effect attributable to physio would exceed any observed effect of invasive venoplasty (if there is any). Of course, in light of the questionable association between CCSVI and MS (i.e. pending verification from groups NOT associated with Paolo Zamboni), such trials of the "liberation" treatment are premature.

Megacode

Well, sort of:



One week til being "on service" and getting a call schedule. Clerkship's pending...

Alberta > Saskatchewan

At least insofar as the MS/CCSVI controversy goes:

Many people hope that CCSVI will prove to be the cause of MS but, at present, this idea is not supported by fact.

Alberta Health Services has compiled an excellent fact sheet about the issue, answering all the canards and faulty bits of reasoning brought up in the debate.