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During this year, by far the most discussed rotation among us 3rd years was Surgery. This is true for a variety of reasons, many of which are probably apparent to non-medical people. First off, surgery is an interesting subject that most people won't ever observe in their lives. So there's a cool sense of "belonging" to the medical community that comes with being in the OR, however silly that sounds.
Surgery is a specialty where the highs and lows of emotion you feel are both primitive and magnified. What do I mean by this? It's a given that the interventions are usually direct and immediate, and that the patient is usually very grateful. The tactile nature of even the simple procedures are satisfying in an immediate way. The friction between your instruments and surgical gloves, gripping the loaded needle driver in one hand with pickups in the off-hand, puncturing the skin with the suture, tying the surgical knots - enjoyable and rewarding on a simple level in comparison to, say, putting in orders or writing notes. (By the way, surgeons do also put in orders and write notes. They just do them much faster, partly because they are really managing only a limited number of pre/postop things.) One of my friends got to cut out the gallbladder during a lap chole. Another had to do CPR on a hemorrhaging patient in the OR (much less happy story). It's stuff like this that makes me understand why people go into surgery, despite the horrible hours.
On the other hand, a difficult surgery is frustrating on that same level. Imagine trying to tie your shoes with chopsticks while looking through a microscope. Even the best surgeons have days where they are a bit off: The orientation of the surgical field is confusing; his grip on the tissue slips repeatedly; there is lots of bleeding; sutures break; steps have to be retraced; the patient has the body habitus of a hippo; etc etc. And everyone is the OR is watching and waiting for you.
When things are going well in the OR, everyone's happy. The attending is having a good day, moving through difficult technical stuff with facility. With the time he's saved, the attending lets the resident practice a little more, providing tips and encouragement. The resident lets the student practice some new suturing techniques during closing. The nurses are in a good mood because things are moving along and everyone's organized. Even the anesthesiologist cracks a joke or two. That's a pretty nice environment to work in, right?
I've had the fortune of working with mostly very good-natured attendings. But there is also no shortage of stories from any medical student about working with the stereotypical God-complex asshole attending who has the entire OR feeling uncomfortable and belittled. The hierarchy is extremely clear in the OR, for better or for worse.
I spent two weeks in the Burns ICU while on the rotation. First off, some free unsolicited advice: Don't chase people around bonfires at 5 am. Don't hold your kids while changing the gas in the generator. Don't become a fireman. Don't let your 3 year old try to grab a hot bowl of ramen from a tall counter. Don't use your foot to start a trash fire. And for godsakes, DO NOT SMOKE while you are wearing a nasal cannula hooked up to a flowing oxygen tank.
Yes, I saw all these things.
I felt enormously sorry for every single patient I saw in the ED that was going to be admitted. They had no clue what they were in for in the next few weeks. A superficial second degree burn is the most common and easily treated of people that get admitted. The good news is that they usually won't need a skin graft, which is reserved for 3rd degree and some deep 2nd degree burns. The bad news is that 2nd degree means your nerves are intact and firing away the pain signals like 200/200 stimmed marines.
Burn wounds need to be cleaned almost every day. For most patients, this means The Tub. The Tub is a large rectangular metallic container in which burn patients soak while the nurses/doctors take down the previous day's dressings and scrub scrub scrub. I have heard the Tub also referred to as the "metal grave." Basically, all the necrotic tissue (a very distinct smell, to say the least), has to be scraped away to prevent infection and visualize the healthy tissue underneath. Imagine getting a nasty sunburn on your belly, then accidentally scraping it with a carrot peeler, and then pouring lemon juice, salt, and habanero sauce all over it. From the screams of agony that accompanied every day I helped with the Tub, that description is an insulting mockery of what it actually feels like. I've seen muscle-bound men reduced to choking out pathetic whimpers, begging for pain medication every 30 seconds. It is in essence being skinned alive every day for however long it takes.
The hands, arms, armpits are all extremely sensitive areas which are, unfortunately among the most commonly burned areas.
I scrubbed in for several skin grafts as well. Much easier on the conscience to scrape when the patient's off in lala land. They keep it quite warm in the OR, as burn patients lose heat at a high rate. I used a potato-peeler type tool to debride the necrotic tissue, and I got a chance to handle the "skinner" machine on the donor sites.
Decent amount of psychiatric stuff going on also. Burns are traumatic. Flames are easy things to visualize when you close your eyes. I'm guessing anticipating having to go to the Tub everyday doesn't help either. Definitely not for the weak of heart.
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fascinating read
do burn victims often contract infections after the initial treatments?
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Ah the burning portion reminded me of a forensic case I worked on a couple months ago that involved two young girls dying in a fire, never forget that smell or the dissection.... Very interesting post though, so your 3rd year in eh, Where do you go?
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Very interesting read, even if it did creep me out when you started talking about "the Tub." I now have a new fear of firey things.
I could never become a surgeon. I'd crack under that sort of pressure like an egg. So much on the line everyday and the hospital always smells like blood, disease, and antiseptics.
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Yea fascinating read.
You can really tell by the way you express yourself that you like medicine, and that you'll prolly be a great doctor.
5/5
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On July 11 2010 10:57 Elegy wrote:
fascinating read
do burn victims often contract infections after the initial treatments?
I didn't see any, but then again most of the patients I saw didn't have burns >30% total body surface area. We use the antibacterial Silvadene on most wounds. I did see some infected staple sites after the grafts, but those are pretty minor.
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On July 11 2010 10:57 Slaughter wrote:
Ah the burning portion reminded me of a forensic case I worked on a couple months ago that involved two young girls dying in a fire, never forget that smell or the dissection.... Very interesting post though, so your 3rd year in eh, Where do you go?
Gonna apply for residency this year. We'll see how it goes.
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On July 11 2010 11:01 LaLuSh wrote:
Yea fascinating read.
You can really tell by the way you express yourself that you like medicine, and that you'll prolly be a great doctor.
5/5
Thanks, that's a very nice compliment.
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I got a 3rd degree burn without going to the hospital. Guess i'm a G. Shit turned black and leathery and didn't hurt for the first couple of weeks. Ended up with like 3 months of pain though if I recall correctly. Huzzah for drunken branding
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On the other hand, a difficult surgery is frustrating on that same level. Imagine trying to tie your shoes with chopsticks while looking through a microscope.
Fuuuuck, amazing! Who came up with this?
Mad respect to all of you doing this, I bow low.
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My cousin got 2nd degree burns because the handle of the coffee machine broke or something like that.... She got lucky because she dropped her pants pretty much immediately.
Apparently, it's much, much worse than anything she'd ever had before - and she's had a few broken bones. Sounds really horrible.
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Sounds like fun... in some respects.
What are you planning to specialize in?
Orthopedic surgery was definitely interesting to watch.. one of my favorite experiences while I was volunteering in hospital.
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Probably anesthesiology. Doing the rotation right now. More on that one in a later post probably.
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Awesome read. First blog I've ever bothered to take a look at, and I'm very glad I did. Good luck with the residency, man. I know an anesthesiologist and he likes what he does a lot, I hope you feel the same when all is said and done.
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Thanks for sharing this, and for the prize nugget of valuable advice. 
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Great blog! I have a question though, few days back I saw an article on this woman who got severe burns on her face from that London terrorist attack 5 years ago. A hospital in England somehow treated her face to perfectly normal. Her skin and her face overall looks amazing, as if nothing ever happened. However, in the article they never mention how they treated her. Do you have any ideas what treatments they could've used?
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Interesting read. Burns are brutal. I've known a few people who got it bad. I knew of a girl who basically got burns over 90% of her body due to someone throwing gas on a bonfire. Not cool 
surgery seems fascinating to me. I always dreamed of being a surgeon, but I knew I never had enough patience/discipline to do it
On July 11 2010 10:57 Slaughter wrote:
Ah the burning portion reminded me of a forensic case I worked on a couple months ago that involved two young girls dying in a fire, never forget that smell or the dissection.... Very interesting post though, so your 3rd year in eh, Where do you go?
what do you do
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Shit like that happens more often than I thought. I read a news on how some dude meant to scare someone but ended up lighting 2 people on fire and they both died.
Also, I've been seeing frequent stories about people throwing acid at their ex-lovers faces and they get terrible terrible burns.
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Pardon my ignorance, but isn't anasthesiology hella-boring?
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On July 13 2010 12:12 Subversion wrote:
Pardon my ignorance, but isn't anasthesiology hella-boring?
depends what you find boring?
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On July 13 2010 12:12 Subversion wrote:
Pardon my ignorance, but isn't anasthesiology hella-boring?
Anesthesiology is probably the fastest route to killing someone outright if you fuck up badly. That would add some excitement for me, at least.
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On July 11 2010 10:50 radar14 wrote:
Don't let your 3 year old try to grab a hot bowl of ramen from a tall counter.
This is good advice. I tried to cook a pot of ramen when I was 10, grabbed the pot of boiling water without realizing that the handles were very hot, and proceeded to get 2nd/3rd degree burns on almost 10% of my body (mostly thighs)
I didn't have to stay in the hospital, but I do remember having visit them to take off the bandages daily and clean them. From what I remember, they used some kind of cold, white cream to clean the wounds and it actually felt good despite the fact that I could literally see chunks of my rotting skin being scraped off. I honestly looked forward to the scrubbing, but taking off the bandages was the most painful shit ever oh my god...
Also, some more advice. If you ever get burned, the first thing you should is dump some water on the burns and cool that shit down. I remember my doctor telling my parents that they were retarded for taking me to the hospital right immediately after seeing me get burned; supposedly I had a chance to avoid the 3rd degree burns if I had cooled the wounds within a minute or two of getting burned.
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so are people in the tub not given strong pain meds?
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On July 13 2010 14:30 travis wrote:
so are people in the tub not given strong pain meds?
How would they learn not to do it again then?
User was warned for this post
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On July 13 2010 12:12 Subversion wrote:
Pardon my ignorance, but isn't anasthesiology hella-boring?
I'm in biology research but my gf is currently a 2nd year in med school. Whenever we talk about specialties I always get interested in anaesthesiology. From what I can tell its walking a fine line between killing a patient and having them wake up in the middle of a procedure. Also every patient requires different dosages based on genetics, body size, and probably more stuff I don't know about. It sounds like a difficult art to master, and while the anaesthesiologist doesn't directly do the operation, he makes the operation possible and that sounds extremely appealing to me. Oh that and the fact that they get paid a shit ton of money.
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On July 13 2010 04:54 YoonHo wrote:
Great blog! I have a question though, few days back I saw an article on this woman who got severe burns on her face from that London terrorist attack 5 years ago. A hospital in England somehow treated her face to perfectly normal. Her skin and her face overall looks amazing, as if nothing ever happened. However, in the article they never mention how they treated her. Do you have any ideas what treatments they could've used?
I would guess a skin graft if it was a deep burn. That's the only treatment I'm aware if it's that deep. They take a very superficial layer of skin from somewhere else on your body (typically your legs since those are less likely to be burned), make a mesh out of it, and then staple it to the recipient site. If they weren't that deep then they can heal on their own. In fact people who recover from these more superficial facial burns look like they just got a facelift i.e. less wrinkles etc.
I'm sure there are other treatments and plastic surgery options I'm not aware of.
On July 13 2010 12:12 Subversion wrote:
Pardon my ignorance, but isn't anasthesiology hella-boring?
I'm not going to go ahead and say it would be "exciting" for everyone, because surely it wouldn't be. I'll give you one analogy that's pretty common. Anesthesiology like flying a plane. Takeoff (induction, intubation) and landing (recovery of spontaneous respiration and extubation) are the most "exciting" and critical times. For the actual "flight", if you're doing your job correctly, things should look like they're operating pretty smoothly aka boring. Once in a while the plane will start to crash mid-flight and you'd better know what you're doing to make a landing.
Anesthesiology is applied pharmacology and physiology. You push a drug and you see its effects immediately (or soon thereafter). Patient's heart rate is going into bradycardia? Give some atropine and monitor, keeping some phenylephrine on hand. He's going into tachycardia? First instinct is that the patient's in pain. Give some more fentanyl first. Patient is hypertensive? Try increasing the volatile anesthetic first for cardiac depression, then consider a beta blocker. Watch, act, react.
Also lots of procedures for people who like using their hands. Intubations, arterial lines, central lines, nerve blocks, etc.
It will certainly become "boring." That comes with the territory of being proficient. If you're doctor is genuinely excited to be treating you, chances are that either he's a newbie/sucks or you're fucked because he's going to get published writing up the strange new disease that you have.
On July 13 2010 14:30 travis wrote:
so are people in the tub not given strong pain meds?
They are given repeated doses of strong meds. Morphine and fentanyl are the strongest drugs that are used regularly for pain control in the hospital setting.
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17070 Posts
And people can still feel it through the morphine? X_X
As always, I really enjoy reading your threads
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Unfortunately, yes. Then again, how much pain medication you give is completely dependent on the attending in charge. While the rest of us are squirming from screams of "Oh God, please stop AHHHHH", she was calmly going to town on the poor guy's arm like she was filing her nails. I never did question her methods because I am too young to die.
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17070 Posts
On July 14 2010 10:21 radar14 wrote:
Unfortunately, yes. Then again, how much pain medication you give is completely dependent on the attending in charge. While the rest of us are squirming from screams of "Oh God, please stop AHHHHH", she was calmly going to town on the poor guy's arm like she was filing her nails. I never did question her methods because I am too young to die.
And what would the consequences be to the patient if the wound weren't completely debrided?
Also, did you ever decide on that whole Durham thing?
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On July 14 2010 10:26 Empyrean wrote:Show nested quote +On July 14 2010 10:21 radar14 wrote:
Unfortunately, yes. Then again, how much pain medication you give is completely dependent on the attending in charge. While the rest of us are squirming from screams of "Oh God, please stop AHHHHH", she was calmly going to town on the poor guy's arm like she was filing her nails. I never did question her methods because I am too young to die. And what would the consequences be to the patient if the wound weren't completely debrided? Also, did you ever decide on that whole Durham thing?
Increased risk of infection. Necrotic tissue is a cesspool of stuff you don't want next to healthy viable tissue. And you need to see the lowest layer to determine whether the patient will need a graft.
About Durham, I'm definitely applying there but whether I can invited is out of my hands
From the people I've asked, they really only take superstars. Still wanna visit sometime though~
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17070 Posts
On July 14 2010 10:44 radar14 wrote:Show nested quote +On July 14 2010 10:26 Empyrean wrote:On July 14 2010 10:21 radar14 wrote:
Unfortunately, yes. Then again, how much pain medication you give is completely dependent on the attending in charge. While the rest of us are squirming from screams of "Oh God, please stop AHHHHH", she was calmly going to town on the poor guy's arm like she was filing her nails. I never did question her methods because I am too young to die. And what would the consequences be to the patient if the wound weren't completely debrided? Also, did you ever decide on that whole Durham thing? Increased risk of infection. Necrotic tissue is a cesspool of stuff you don't want next to healthy viable tissue. And you need to see the lowest layer to determine whether the patient will need a graft. About Durham, I'm definitely applying there but whether I can invited is out of my hands From the people I've asked, they really only take superstars. Still wanna visit sometime though~
Ah, I'm only here for two more years (going into my junior year), so let me know :D...it's a real foodie town. Just got featured in the New York Times. They're really cleaning up the place, actually. And if it's of any use, it's also very gay-friendly. Especially for a southern city :O...that in addition to the other good stuff about it that I told you about before.
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EPT
