Week 3: A day in the cath lab

Last week I got to watch two cases in the cath lab. There were a few particularly cool things about this experience.

1) I got to scrub in both times.

I'd never done this before, and I found it a lot trickier than I had anticipated. Making sure your fingertips don't get any drips from the rest of your arm is tougher than it sounds (this is because your fingers are supposed to be the absolute cleanest part, so you don't want to rinse your whole forearm and then have the water from your elbows drip down to your hands...makes sense). Lots of maneuvering at the sink was involved, and then making sure no part of you touches anything that's not also sterile requires careful attention. This is particularly true when you're putting the gown on, which involves holding part of the folded gown, letting the rest of it drop, and putting your arms through simultaneously while spreading your arms out wide to maneuver the gown up your arms. Anyway, I'm sure I'd eventually get used to it, but it was definitely a learning experience in paying attention to detail. I think the hardest part was resisting the urge to scratch any itch on my face, which happened a lot with the mask I was wearing. I wore one with a splash guard to protect my eyes, so there was even less ventilation around my face. I was also wearing a 30 lb lead apron (lead collar, vest, and skirt) to protect from radiation, plus scrubs, the gown and a hair hat. I have a newfound respect for surgeons and interventionalists who perform hours upon hours of procedures at a time while standing with all that gear on. It's not easy, and I was only on my feet for about 2 hours at a time.

2) Because I scrubbed in, I got to stand close to the table and see things.

It was absolutely incredible to watch the interventionalists snake catheters up the femoral artery and into the heart, and I still don't understand how they knew where they were in the heart. The screens that they look at project X-ray images that show where the catheter is, but none of the soft tissues (i.e., the heart, veins and arteries) show up. The only time I could make any sense of how they knew where they were was when they injected contrast (the dye), which darkened whatever area the catheter was in. So besides the simple act of maneuvering the catheter, I thought the coolest part was watching them balloon a stenosed (narrowed) pulmonary valve (the valve between the right ventricle and the pulmonary artery). This is called a balloon valvuloplasty. For whatever reason the leaflets of the valve were closing too tightly, so they used a little balloon at the end of a catheter to stretch them out. That way the right ventricle doesn't have to work so hard to pump blood to the lungs because the pathway between the two is wider.

3) More puzzle solving was involved, which I always find interesting.

I found it very cool how they used various bits of information to get a full picture of what was going on in the heart so they could select the appropriate treatment. For example, some of the catheters have pressure transducers at the end to take pressures from various parts in the heart, which the interventionalists use to gather information and make diagnoses. So, for the narrowed pulmonary valve case, they measured the pressure gradient between the right ventricle and the pulmonary artery and found that the pressure in the RV was a great deal higher than it should've been compared to the pressure in the PA. This is a sign of pulmonary valve stenosis because the right ventricle must work extra hard to pump blood through the very narrow opening, which causes the pressure to be higher than it normally would be. I'm sure this is an overly simplified explanation, but even understanding such a tiny amount was exciting.

So, I spent a day in the cath lab, and I'll get to observe in the operating room later this week. I'm thrilled with how much I'm getting to see, and I can't believe I'm already in my fourth of five weeks. Trying to soak it all up :)

Week 3: Chief's case

Every morning in the pediatrics department there is a meeting called Morning Report, during which residents present all the cases on the pediatrics floor, and then at the end, someone gives an informative presentation on a topic of his/her choosing. Today, the presentation was a chief's case -- an interesting case that the chief resident presents, followed by a discussion in which the interns and other physicians in the room figure out the diagnosis.

This was the most interesting meeting I've sat in on yet. It gave me a glimpse into the realm of medicine that involves solving puzzles. To a certain degree, every morning on rounds is a puzzle in the sense that keeping a patient stable in the PICU requires a delicate balance of various meds. But most of the time (at least as far as I can tell), by the point the patient is under the care of the cardiologists, the diagnosis has been made.

What I saw today involved figuring out why a baby arrived at the emergency room with a fever, cough, and reddish purple coloring. After that description, the chief turned it over to the interns and said, "OK, so what do you want to know?" And everyone worked together to get to the right diagnosis -- there was brainstorming and discussion and questioning of why the interns wanted to know certain things (e.g., why do you care about sodium levels?). The level of challenging seemed just right -- they had to defend their reasoning, but nothing was ever combative. Overall, it seemed like a supportive learning environment, and one that reminded me a lot of discussions at Bennington.

Eventually, they got to the correct diagnosis of nephrogenic DI (diabetes insipidus), which occurs when the body can't concentrate urine because of insensitivity to ADH (anti-diuretic hormone). Treatment includes medicines (e.g., hydrochlorothiazide) that are actually diuretics, but can also reduce urine output in people with NDI. I don't understand the mechanism yet, despite my Wiki attempts. I'm still unclear how reducing the permeability of the distal convoluted tubule to NaCl (thereby causing less water to osmose from the tubule into the interstitium, resulting in more water lost in urine) would treat the condition. But hey, I know some people who would know, so I'll find out why.

The more I'm here, the more I realize that, when dealing with sick babies as a medical student, I know one of my biggest challenges will be fighting this tendency:

Week 3: Dinners

I just bumped into one of my new med student friends who lives a few doors down from me. He and his housemates have dinner together every night, and they'll sometimes have a guest come over to eat with them Monday-Thursday, and the guest will then be the guest chef for Friday dinner. He asked if I wanted to join and cook on Friday, so I said OF COURSE! A reason to cook good food?! I have to figure out what to make though...considering the classic yet delicious pasta and peas (pasta with prosciutto, onions, peas, olive oil, and romano cheese). This will also fit my budget and is a tried and true classic. Looking forward to a week full of getting to know my new neighbors and friends :-D Photos of meals to come, of course.

UPDATE: I forgot to take pictures of my meal, but here are some pictures of the prep and finished product of the yummy pizza one of the guys made on Wednesday. I chopped the peppers to help out, which I thought looked pretty and ended up on a siracha-pepper pizza, and the other two pizzas were pepperoni and mushroom/arugula/balsamic. DELISH!

End of week 2: Weekend of exploring

Aloha from Charlottesville!

This was the first weekend I was able to get out and about to explore, as there were no surgical cases over the weekend, so no post-op checklists for me to do during rounds. The fellows told me to focus on enjoying this beautiful weekend, so I listened :)

I spent Friday night out with new med student friends I'd met at the hospital. We went to a few bars and it was so nice to get out and be social in a new town.

Saturday I went hiking along part of the Appalachian Trail with my roommate. We tried to hike Humpback Rock, which had been recommended to me a number of times, but the road to get there was closed. So, we took Skyline Drive and drove until we saw anything promising in terms of trails. We found one, and it was beaauuutiful. Despite the snow on the ground, it was warm and sunny enough to go without a coat. If we'd continued along, we could've hiked all the way to Maine, but we called it quits after a couple miles :)

Here was our first stop at a scenic view.

Roomie with her two awesome dogs, Lola and Haley

It's no Hawai'i, but this isn't so bad :)

Saturday evening I joined my new friends for some fresh pasta making. This was quite an ordeal and required lots of teamwork as you can see from the strands of pasta that were multiple feet long. We made regular and spinach dough, which was shaped into linguini, tortellini and ravioli. I had never made fresh pasta before, and I think I'm converted. It was so fresh and delicious.

Flattening thyme-infused sheets to make ravioli

Waterfall of pasta!

The tortellini and ravioli had two types of filling: sweet potato and mushroom/onions. Both were INCREDIBLE. I think I ate my bodyweight in pasta, and there was still plenty leftover.

To-die-for-tortellini.

I couldn't show up empty handed, so I made my famous cookies (my Bennington and Hawai'i friends know all about these puppies). They must've been liked because I left with a bare plate.

Most incredible cookies in the world

After dinner we played dominoes and Catch Phrase. It was so great to see how close these students were, and that despite being in the thick of third year, they still make time to hang out and have fun (one of them was on surgery rotation, and yet was still there and awake. Impressive!).

Sunday was a day for exploring in 55 degree sunshine. I walked all around the Downtown Mall and found some quaint bookstores and an awesome little coffee shop with a great vibe, along with plenty of gelato places. It reminded me a little of Pearl Street in Boulder.

Downtown Mall

Public chalk board

I finished my moseying with a stop at UVA's pool, where I actually competed as a junior diver about a decade ago. I hadn't been back since, but it looks exactly as I remember it. An old teammate of mine now holds the guys' record on 1-meter and 3-meter, and I saw plenty of other familiar names on the record board.

UVA pool

Back at work tomorrow bright and early. Later this week I'll get to shadow in the cath lab, which I'm so excited to see. Next weekend I'm planning to go to Monticello and also to watch the UVA men's tennis team play matches (they're #1 in the nation...should be pretty intense). More to come!

Week 2: Thursday

I've been at rounds now for 10 days and I'm understanding more each day. Even if I don't know exactly what a certain term means, I can at least recognize it and place it in context. For example, I know a BUN test is an indication of renal health, and ALT is a measure of liver function. That way, even if I don't know what the numbers indicate, I can follow the general subject they're discussing.

On Monday I sat in on another fellow expansion meeting, where the pediatric cardiology fellows and attendings discussed two new articles in the literature. I was pleasantly surprised that the way they went through the paper was very similar to how we go through papers at Bennington. Clearly articulating the research question being examined, the methods used, and interpreting the results is what we focus on in class, which is what I saw here as well. This may seem like it's a given for how to discuss articles, but this semester was particularly heavy in journal article reading in my physiology class, so it's exciting for me to see the skills I'm learning be applied in the real world.

Yesterday was another cardiac surgery conference where the upcoming cases are discussed among pediatric cardiologists and cardiac surgeons. One case was to correct a vascular ring, which I learned is a defect in the development of the aorta and surrounding vessels. This often causes a double aortic arch where the aorta splits into two vessels after it leaves the left ventricle, and these two vessels then wrap around the esophagus and trachea and compress them. One of the doctors tried to show me on the echo how you can recognize a ring, but I still couldn't really make sense of it :-/. In the same meeting I saw real time images of an angiogram, where dye is released through a catheter into the vasculature. It was one of the coolest things I've seen yet, and shockingly beautiful. It really brought all the textbook studying to life as I clearly saw various arteries darken as the dye spread through them. My obvious awe led one of the docs to suggest I get down to the catheter lab to watch an interventional procedure.

Picture of a cath lab (courtesy of Wikipedia)

So, today I got to see the cath lab, got a pair of scrubs, and will be schooled in the art of scrubbing in before I watch a procedure in a week or so. It still boggles my mind that they can thread a catheter up through the femoral artery to the heart in a little baby. Can't wait to see it happen.

Other than that, research is still up and running and I'm speaking up during rounds to do my job of running the clinical pathway checklist. It's a learning experience for all of us as this is a new protocol here. I'm very excited to have an active role.

Looking forward to meeting some medical students tonight for dinner. I found out they live in the same development as me, so I'm walking 30 yards to meet them at their house with a salad in hand to share :)

Week 2 underway

My second week here is underway and I'm really enjoying everyone I'm meeting. I had a nice long discussion with one of the docs I'm doing research for today over coffee...it was a chat about the research project first, and then we just started chatting about general things like my old job, interest in medicine, prospects at getting into schools (nice to talk about this with someone who is in the field), and his work and other projects he's involved with.

That meeting was followed by two hours of researching in the library, followed by a lunch meeting with the two main docs I work for, followed by another meeting about my other main project with some data analysts and quality control folks. Lots to talk about! I'm excited to get down to business and start getting real data in place for analysis so we have some numbers to crunch and results to show.

I also met with an admissions officer briefly and spontaneously to talk about the application process, which was incredibly enlightening and helpful, and just in general set my mind at ease that I was hearing these things from a med school official (as opposed to freaking myself out reading studentdoc forums).

Last meeting of the day is in a few minutes to hammer out a way forward for one of the projects, and then I'll head home to exercise.

P.S. I'm still in love with working with little babies.

End of week 1: Babies

During rounds on Saturday, I was allowed to go into the PICU rooms while the babies were examined, and I even got to do a little examination myself. For one tiny patient, I got to feel the two fontanelles (soft spots) on the head (if blood were pooling there, this would be a bad thing), feel the pulse in the tiny feet, and listen to the heart beat with a stethoscope. I'm sure for med students and residents this is probably no big deal, but I was thrilled to be allowed to participate even ever so slightly. I can't imagine anything more rewarding than helping a sick baby get well enough to go home. Overall: great morning!