That's ironic right?

So all of last week and for the rest of this week I've been on doing my ward experience with the Acute Care Surgery service. This is the surgical team that deals with trauma and emergent surgical cases that present at the Loma Linda University Hospital.

Ironically even though I'm with a surgical service I somehow missed any time in the OR all of last week. I was hearing stories from classmates in other surgical services about being in the OR everyday and to be completely honest I was getting a bit jealous.

Beginning this week our team got a new attending physician and a couple of new cases that could potentially be managed surgically. Yesterday morning the team saw a woman in her mid-twenties who had a 5 month history of small bowel obstruction. In other words the thought was that something was obstructing the natural pathway of digestion.

Today I got to scrub in on the exploratory laparotomy, which means I had the ability to be in contact with the sterile area during the surgery. Its a whole different mindset when you're wearing a sterile gown. You have to resist the urge to scratch an itch on your face or adjust your glasses. Anything you touch that isn't sterile means you have to re-gown before you can get near the sterile field again. I was in the OR with the surgery attending, the senior resident and one other third year medical student. Since there were fewer people I was able to be really hands by helping hold parts of the bowel as well as suctioning.

The patients small bowel had a lot more motility than normal which gave it a pretty weird appearance. When the bowel was visible the entire small intestine was wiggling a lot more than normal. The surgeon examined the small intestine to look for a potential obstruction and couldn't find one but it soon became apparent that the peristaltic activity of the bowel was not moving any of the stool. To alleviate this problem the surgeon made two incisions in the bowel and inserted a catheter into one and flushed saline into the intestine. He then ran the bowel to force the stool out of the other incision farther down the bowel. According to the attending and the resident the consistency of the stool was abnormal and indicated the patient could have cystic fibrosis.

Since the surgery started so late I had to leave for class before they closed the wound. After spending all that time on the surgery service this one case more than made up for not getting any OR time in the past week. If I'm lucky I might get scrub in on another case later this week. On Monday we start classes and we won't get any clinical experience until next summer so I'm trying to soak up as much as possible because I know I'll need the motivation later on in the year.

Some specialty stereotypes

Reposting this from the LLUSOM Facebook group. It gave me a good laugh.

Impressions

I'm exactly 7 days into my first year of medical school. So far this week has consisted of mind-numbing orientation sessions, organizing my new house, and most importantly following med students and residents on rounds in the hospital.

In the past 7 days I've been bored, overwhelmed, nervous and excited sometimes all at once. I've known for 8 months that I would be attending Loma Linda University School of Medicine, I've known for much longer that this career choice will define the rest of my life. Up to this point this knowledge has been purely intellectual, however in the past week it has become a reality. Beginning with this week I've entered into a new stage in my life, one that will be forever defined by my career as a physician. My current reality won't change much for the rest of my life.

At the same time these are sobering thoughts they are also exciting and inspiring. Today we spent the afternoon listening to faculty physicians from the School of Medicine talk about their various specialties. Listening to these doctors, it was clear each of them had a passion for their specialty. I learned a little about personality types in medicine and more about how competitive each specialty is. Most of all I was reminded that although the path will be daunting the end will be very rewarding.

All in all its been a good week. We have one more week until classes start and although I'm valuing the free time I'm getting anxious to start learning (I'll probably slap myself for saying that in a month).

In the meantime I'll make an effort to update this blog more frequently with interesting updates about medical school.

She just wanted her mom...

To start my theme of inteteresting experiences I'll relate one small experience from the last 6 months as an illustration. I work as a phlebotomist at large a hospital here in Lincoln, Nebraska. Because of its colocation with the the alcohol independence center and psychiatric units as well as its geographic location, the emergency department at this hospital recieves a very unique slice of Lincoln's population. This uniqueness is often more evident on the weekends and after 6 pm in the evening.

This particular evening I was working in the emergency department and I saw orders to draw a patient in room 26. As I walked by the desk on my way to the room one of the nurses called after me, "Wait! let me come help you." Of course I was thinking to myself, "I'm Phil Stokes, I've been doing this for so long, I don't need any help thank you." I conveyed this to the nurse in a more polite fashion and continued on my way to the patients room. In the room I found a very calm looking woman in her mid forties who we'll call Lucy. The only thing that caught my eye about Lucy was the fact that she was in restraints, strapped to her bed.

I often draw blood from patients who are in restraints so I didn't think anything of it. As I walked in I gave my usual greeting, "Hi my name is Phil, I'm from the lab, I need to draw a little bit of blood from you" I even added an extra "Is that ok with you?" I thought I'd cleared the major hurdles to a successful blood draw but as soon as I tied my tourniquet and began to look for a vein Lucy began to scream "MOM...MOOOMMMM!" and started squirming and fighting at her restraints. This led to some consternation on my part and many people including the police to run into the room. After me, two techs, two nurses and a police officer had sufficiently secured Lucy, I proceeded to draw my blood but not without continued ear-piercing appeals from Lucy for her mother.

Just another night in the emergency department.

Nothing interesting has happened?

Its been a while since I've blogged about anything substantial. I've been justifiying it because I thought nothing interesting has happened in my life recently. I look at other people who blog. like my friend Dylan Wren, and see tales of adventure and roadtrips around the country. My experiences here in Nebraska pale in comparison I say to myself, but the other day I realized that a lot of interesting things do happen in my life and often on a daily basis. So I've resolved to chronicle more of the interesting things that happen in my life in this blog.

Dylan Wren, a true American.

Whitney rocks the 12 guage...

This and that...

So its been almost a week since I took the MCAT and I'm trying to adjust to the idea of not having anything to do. I'm looking for a job in the wonderful job market of Lincoln, Nebraska but I've had a chance to do some pretty awesome stuff the last couple of weeks so I thought I'd give a little update.

The second amendment can be fun!

Physics 1 is over!

On Saturday I got my grades back from the first session of physics at UNL. I was pleasantly surprised to find a grade much better than I had expected. I can only attribute this to the grace of God and his assistance in my life up till now. Physics is a tough subject and compressing one semester into 5 weeks has made it one of the toughest classes of my college career up till now.

Right now I'm a week and one day into the second five weeks session which is so far proving to be just as tough as the first. I have to remind myself daily that my God is behind me every step of the way and I can trust in him to give me the gift of understanding. My God is powerful and I have been reminded of this power during this physics ordeal. I can look to him for assistance whenever I need it. With God its on to the next challenge Physics II!

Nothing beats breakfast at the Crete Airport.

A few of us went down to the monthly EAA breakfast down at the Crete Airport this morning.

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Dairy Sweet!

Went to this sweet ice cream place out by Pioneer's Park. Lemon ice cream is the best.

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Possible New Bridge Jumping Site?

James and I saw this bridge from the air on the way back from Tarkio, and decided to check it out for a possible bridge jump site.

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Tarkio, MO Fly-in

A vintage T-6 Texan at the Tarkio Fly-in

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Bridge Jumping

Some crazy kids who have had enough of Nebraska and decided to jump off a bridge.

Physics, my bane.

So I'm a week and 2 days into preparing for the MCAT which I take on August 19. I can now identify with that often repeated Chinese proverb ; "Even the longest journey must begin where you stand." The Kaplan MCAT Course starts off with Physics, a class I'm taking at UNL later this summer. Needless to say, its proving a challenge to understand material from a class I haven't taken yet. But the kind folks at Kaplan assured me that this is the best method for my situation, and it will only reinforce what I will learn when I come to the real class.

I start the physics class in the beginning of June which means I have about 5 weeks of solid studying, after that the MCAT studying will have to compete with Physics but I think this will be manageable.

This summer is going to be a tough one but I trust that by the grace of God I will get through.

Went to the park...

A couple of pictures from this Saturday at Pioneer's Park.

Hasta luego Francia Sirpi...

Today's the day, the longest day in the longest 3 months of my life, the last day in Francia, the last day before we take one more terrible deuce ride into Puerto Cabezas. It’s a wonderful feeling, it means that soon I'll have internet, flush toilets, warm showers, food other than rice and beans, and all the other comforts that come along with not living in the bush. But its also not without mix feelings that I'm leaving this place; I think I'm actually going to miss this place. Probably when I'm busy beyond belief this summer I'm going to look back at the times when I thought I was so bored and think 'why didn't I enjoy it when I had the chance?'

I'm also a bit discouraged by the immense need here that is not being met, I hope that at some point I'll have more to contribute to these people. There needs to be a concerted effort at educating the Miskitos about how to improve their health and livelihoods. Until this happens clinics and de-worming medications are only a stop-gap measure.

One crazy week in Krin Krin...

Our week on the Rio Coco started last Sunday when we left Francia for Waspam. We spent Sunday buying food for our trip and spent the night at an establishment called El Piloto or The Pilot. Even though the power was out half the time it was definitely the classiest hotel in town…it even had A/C and wifi.

Monday morning we drove the deuce over to a small town on the river called Lamos where we met the boats that would take us up the river. The boats on the Rio Coco are basically 65 foot dug out canoes with out board motors and it took two of these to ferry our group and gear to our destination. Krin Krin is a pretty remote village on a river with a lot of remote villages. Besides trails through the jungle the river is the only access to the outside world for most of the villages along the Rio Coco. Krin Krin itself is about 10 hours by boat from Waspam.

Over three days we saw over 400 patients which is pretty amazing since we only had one licensed provider with us. A lot of the patients we saw had hiked in from surrounding villages to reach our clinic. The doctor that was supposed to come with us got sick right before the trip and wasn't able to come. We set up three consultation stations and Jeff floated between each one and helped with the complicated stuff. The way the rotation worked out I got to be in consultation part of the first day and all of the second and third days. It was pretty cool to be able to put all the knowledge we had gained working with Jeff and Dr. Linares to work on our own. I made a cheat sheet of all the common drugs and symptoms of disorders that helped a lot. It also helped that almost everyone had the same symptoms too. The vast majority of the people we saw had parasites that could be treated with one a couple of different medications. Parasites are so commonplace that a lot the patients wouldn't even bring up the fact that they had them. For some reason a lot the kids had ear wax issues and we spent a lot of time digging wax out of ears which made for some very unhappy children, I actually pulled a chunk of wax the size of a bean out of one kid's ear. Most of the kids had never even seen a white person before, let a lone one with strange things like stethoscopes and thermometers so we had to deal with plenty of freaked out, screaming kids. For 10 hours a day in an enclosed space screaming and crying kids starts to get to you. Sadly the majority of the women patients we saw had urinary tract infections and a lot of them also had STD symptoms. We did a lot urine tests for infection and prescribed lots of antibiotics for sexually transmitted infections. Unfortunately we had to tell a lot of the people we saw that we could help them and that they needed to visit the hospital in Waspam. One family hiked two days through the jungle after hearing that we were doing a clinic in Krin Krin. They arrived with a very sick baby only an hour before we were supposed to leave yesterday and we were able to evacuate the mother and baby to the hospital in Waspam with us.

One of the most interesting things about Krin Krin is that it is the focal center for something known as the Grisi Sickness. Grisi means crazy in the Miskito language and it can best be described as demon possession. It apparently started about 70 years ago in Krin Krin and mainly affected adolescent girls and young women. There are stories of teenage girls overpowering and killing soldiers that accompanied the government medical teams that first tried to figure out what was happening. The World Health Organization has sent teams to investigate the problem and has classified it as group psychosis that only seems to affect young women. Jeff had brought this up in our Emergency Care I class last semester but I had forgotten until Jeff reminded us about it last week. It was a little unnerving to know that this is where it all began and it might still be happening but I didn't give it much thought. The night before we left all the churches in Krin Krin got together for a farewell service for our group. We sang a lot of songs and it was a lot of fun to worship with the people we had been working with all week. At the end the pastor got up to give a short sermon and soon after he started a girl in the back fell down and started having convulsions. I wasn't close enough to see exactly what was going on but Jeff said it was definitely not a seizure. It took several people to hold her down and her movements were definitely too deliberate for someone having a seizure. The weirdest thing about it was that she was completely silent, normally someone like that would at least have to make some noise. After a few minutes several people carried her away kicking, but strangely not screaming. After the service was over we got together and prayed as a group but we never heard what happened before we left.

My week on the Rio Coco was probably the highlight of my time down here in Nicaragua. It was the epitome of why I was down here; to put my limited medical skills to use in helping these people. Up till now our clinics have been limited by time and distance from Francia, but in Krin Krin it was awesome to be able to keep the clinic open as long as possible and be able to help as many people as possible. It was saddening to know that people had to walk for hours and sometimes days through the jungle just to reach our little temporary clinic because it was the only medical assistance available anywhere near where they live. A man in Krin Krin told us that the government clinic was built but there was no doctor, no nurse, and not even any medications. There is a terrible need for medical assistance in this area which is not being supplied by the government. I hope I can come back in the feature and contribute more than I was able to on this trip.

Appendicitis Update

We arrived in Waspam this morning and I went by the hospital here about half an hour ago to check on the patient we brought up on Wednesday with appendicitis. I asked the nurse if there were any patients from Francia with appendicitis how they were. She went around asking people and we found the patient sitting with his family in the courtyard of the hospital looking quite healthy. It was really cool since I wasn´t very hopefull about his prospects before, please keep this guy in your prayers that he will make a full recovery.

Appendicitis!

Around noon Wednesday was turning out to be a pretty normal day with Matt, Dan and I watching a couple of episodes of how I met your mother under one of the buildings to escape the heat. In the middle of our second episode Jeff walked over and asked if we wanted to help transport a patient with suspected appendicitis to the hospital in Waspam. After about a third of a second we decided, 'yes that would be a good idea and when we're we leaving?' The cooks handed us lunch in a bowl and we ran to the truck for the ride to the clinic. When we got there we found the patient waiting in a room with an IV already started by Maria. Apparently the sense of urgency ended there because we ended up waiting at the clinic for over almost an hour. During this time the Doctor and Maria tried to call an ambulance and then when that wasn't an option a debate ensued about whether to drive the patient out to the main road and wait with him until a vehicle heading to Waspam passed or to drive all the way in the deuce.

Eventually the conclusion was reached that we should drive the deuce all the way to Waspam and we loaded up the patient and rolled out. I can't imagine a ride in any vehicle over these roads would be the best idea for a patient with acute appendicitis, but being in the back of the deuce is especially punishing. We set up a small cot in the back and the driver tried to take it slow but that didn't seem to improve things very much. The shocks on the truck are very stiff for heavy loads and with not much weight in the back it’s a very bumpy ride. I was kind of expecting to have to do some kind of EMT stuff on the ride up but we really didn't have to do much of any thing. We made it to Waspam and the hospital in about 3 hours and went right to the hospital. The hospital is close to the outskirts of town and is apparently staffed by Cuban doctors and nurses.

Once we dropped the patient off the medical portion of the trip was over and we went shopping for the mission. On the way to one of the stores we stopped by the Rio Coco that separates Nicaragua from Honduras. There isn't much on the other side and there is no bridge connecting Waspam to the Honduran side. Apparently the only way to cross is by boat and it didn't look like there was any kind of border security on the other side either. Apparently the Miskito people can cross freely without a passport since they live on both sides of the river. Waspam is smaller than Puerto Cabezas and seems a little cleaner and maybe less busy.

After shopping we went to an internet café by the airport (really a grass runway with a two room terminal) and got a few emails out. After that we loaded up the deuce and got ready to head out of town. On the way out we stopped by the hospital to check on our patient and found out that he had already been to surgery but unfortunately his appendix had already burst by the time they opened him up. With the age of the patient, he was over 60 which is very old for Miskitos, and the rough ride to town I don't think the prognosis is very good. Since then I haven't heard anything but I may try to check when we head back to Waspam this Sunday for our river trip.

It was a unfortunate dichotomy to the day; on the one hand I was excited to get out to civilization, get a cold coke, by some food, and get internet but on the other it was because someone was seriously ill. Its pretty easy to get jaded here by people's medical problems, many of which are a result of their lifestyle, but this patient was sad reminder of the heath reality these people face. It hit me when I got back to Francia that this guy might die and I was excited that I had gotten a cold drink…I felt pretty guilty after I realized that.