One more day

Long day today, but a fairly decent one.  It helps when you're doing something that makes a difference, you know?  Even if your part in that is very small (as mine most assuredly is at this point), it remains a day well-spent.  And in this point is the fundamental irony of Magee (and of too many other hospitals around the country): that at an institution ostensibly dedicated to healing and saving lives, the business of death is the primary focus.  It's an unwelcome shock to look at the board where all the surgeries are listed and realize that a full third are abortions of one kind or another.  So while in one room we're doing a radical hysterectomy and lymph node dissection in an attempt to stage and begin treatment of endometrial cancer, the team next door is likely to be performing a suction dilation and curettage (which seems to be the favored form of abortion here).  And that spectre is always lurking in the background, particularly since it's just part of life at Magee -- virtually no one who works here has any problem with it (or even thinks anything of it).  So I guess my sense of satisfaction at being able to play a role in saving a life at least for a time is to a large extent annulled by a growing awareness of what's going on around me.

Regardless, however, I only have one more day to go.  One more day of getting up at 3:30 to pre-round at 4:30, round at 5:30, and present at 6:30.  One more day of trying to save lives surrounded by a culture of death.  One more day on a rotation I've dreaded since the first thoughts of applying to medical school entered my mind.  One more day.  I'll catalog that last day tomorrow, and then on Friday I'll share some closing thoughts about the rotation.  After that, it's on to pediatric emergency medicine, which I've been looking forward to since signing up for it back in March.  It's my payoff for surviving Ob-Gyn, and hopefully it'll bring good stories and ruminations much less discouraging than those from this rotation.  First, though, I need to get through my last day at Magee and survive the test, so prayers would be tremendously appreciated.  Hope you're all doing well...peace and God bless!

Exhausted

Memo to those who don't have a car: signing up for gyn-onc isn't really an option.  4:30 start time today, 4:45 tomorrow...buses don't start running (or rather, won't get to to Magee) until after 5.  The work is good, and there are really no moral dilemmas involved -- you're taking care of women who, for the most part, either are or may be in serious cancer-related trouble.  Sometimes things go well (specimens return from pathology as benign; tumors are resected with clear margins and no evidence of spread) and sometimes things go poorly (a routine procedure suffers a serious complication and the patient ends up losing several liters of blood into her chest or we go to do a simple laparoscopic procedure and find that the tumor has grown and spread), but either way you're doing something that's worthwhile.  If you can deal with the early wakeup times (3:30 or so isn't uncommon), I'd definitely recommend this service over benign gyn surgery (as one of my friends noted, "the case before and the case after mine were both abortions").

Today went more or less ok.  The attending I worked with was phenomenal, and I wouldn't at all mind working with him again tomorrow if circumstances allow.  I also got to see a robotic surgery for the first time -- unbelievably cool.  The machine is undoubtedly expensive, and so is the equipment for it, but the incredible freedom it allows the surgeon may ultimately end up justifying the cost as the technology improves and the surgeons gain more experience.  Unfortunately, also saw one of my patients made CMO (comfort measures only); she's unlikely to survive more than a few days (if that).  Once again, prayers for her and her family would be tremendously appreciated.

Anyhow, I'm exhausted and barely coherent, so I'm gonna head to bed so I can do this all again tomorrow.  Hope everyone is doing well...peace and God bless!

Not much to say

Not much happened today...got in at 5, rounded with the team, spent about 3 hours in the OR (all very short, straightforward cases), and then spent most of the rest of the day reading.  Even got to go outside for some of that reading.  Of course, this is sort of balanced by the fact that I'm supposed to be in by 4:30 tomorrow, which means I need to be up by 3:30.  Yikes.  Otherwise, not a lot to say. 

The rotation is drawing to an end, and I can't really find it in me to be sad about that.  Despite the pleasantly surprising lack of intolerance (with the one previously described exception), the culture at Magee is manifestly a toxic one.  Indeed, the lack of open confrontation is in some ways deceiving; things like abortion and contraception are here so ingrained that I'm afraid it would be possible, almost without realizing it, to begin to accept these things over time.  It is not the overt challenge of the abortionist that worries me most; it is the passive immersion that presents the greatest threat to one's beliefs regarding the value of life.  When the rotation finally ends on Friday, I'll give a few tips in this space on how I think that insidious trap can best be avoided.

Anyway, that's all for now.  If you haven't yet, please take a look at yesterday's post on randomized controlled trials and vote in the poll -- I'd really be interested to hear what people think.  Hope you're doing well, everyone!  Peace and God bless!

The debate over clinical trials

Just read an article about the ethicality of randomized controlled clinical trials, particularly in oncology.  The central argument that the author seems to be supporting is that these trials prevent patients from receiving treatments that could prolong their lives and / or relieve their suffering.  This, she indicates, is a more important consideration than the "statistics" and "science."  While I understand her position, I'm of the opinion that the reason we do randomized controlled trials is to make sure that the therapy being studied is a) safe, and b) effective.  Sure, we could prescribe it to everyone right off the bat, but what if it ends up (as so many chemo alternatives seem to) being less useful than existing medications, or has intolerable side effects?  I don't think it's corporate greed; I think it's good science and good medicine.  I appreciate that it's a terrible decision to have to randomize people into the control arm, to not offer them this hope, but I think it's crucial to know what we'll be offering if and when it is approved.  Would I think differently if I or one of my friends  or family was affected by melanoma?  It's possible.  But I think overall it's too important to know that a drug is more than anecdotally effective before making it available.  Any opinions or comments would be greatly appreciated.

Peace and God bless!

Road trip

Up at 4, in at 5, and freezing all morning...that was how the day started.  Fortunately, it got better from there thanks to having a good team and a very good senior resident.  After morning teaching (which was actually really good...one of the residents did some nice tumor board presentations and one of the surg onc attendings gave a really good look at a relatively new procedure that may allow partial rather than complete removal of the uterus for certain cancers, which in turn often permits retention of fertility -- neat stuff!), the senior told us that there were really no cases for us in the OR today, and that she was going to head to UPMC Passavant (about 30-40 minutes north of Pittsburgh) to help one of the attendings there with a couple of cases.  She told us that one of us was welcome to come along, but we were also welcome to stay and help out with floor work.  After a brief discussion with my classmate, I decided what the heck, why not?  A change of scenery would do me some good, right?

I have to say, it turned out to be a good decision.  I got to scrub in and assist with a pair of cases (including some suturing), got some studying done (our first case started almost 2 hours late), and got some really good one-on-one teaching with the attending and senior resident.  Our first procedure was a laparoscopic bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes, abbreviated BSO) and laparoscopic assisted vaginal hysterectomy (removal of the uterus through the vagina; it's actually a pretty cool procedure) in a patient with complex endometrial hyperplasia with atypia (very high risk of becoming or coexisting with cancer).  It was a semi-involved procedure, particularly the hysterectomy -- all three of us crowded into a small space, with the attending and I holding retractors so the resident could see what she was doing.  It went pretty smoothly, though.  Afterwards, I got to stitch up the umbilicus and got some very useful suturing tips from my very, VERY patient resident (subcuticular suturing is something I need a little practice at...).  The other case was just a brief dilation and curettage (D&C) in a 63 year old patient with cancerous lymph nodes but no known disease focus.  It took about 10 minutes to rule out endometrium as the primary source.

That was pretty much my day at Passavant (well, other than the nurses trying to set me up with their daughters...much laughter was had at my expense).  It was definitely a worthwhile experience, so if you're a medical student and doing gyn onc, definitely take any opportunities that arise to help out offsite.  It's good times -- and highly educational.

Anyway, that's it for me for tonight...I'm bone tired, so I'm gonna head to bed.  I'll be back on Monday with further updates and tales (and possibly briefly over the weekend to comment on football, but we'll see...I'd give that one a Bill Belichick "questionable.")  Till then, peace and God bless!

Gyn Onc

I'm exhausted to the point of incoherence, so this will of necessity be brief.  Gyn onc is, in some ways, a sad but fitting bookend to the experiences of labor and delivery.  In L&D, the patients are new mothers and their children as they make the transition from "unborn" to "born."  Every day is an encounter with the miraculous; every day is filled with lives just starting out.  In gyn onc, however, the spectre of death is very real.  One quick story for purposes of illustration.  Prior to heading into the OR for her surgery, I quickly met and introduced myself to the next patient on the schedule.  MRI had shown an endometrial cancer in her uterus, and the uterus needed to be removed to ensure clear margins.  She had been scheduled for a laparoscopic hysterectomy, and since she was nulliparous (no children) and hadn't had any prior abdominal surgeries, it figured to be a quick and easy case.

Of course, Linakis's First Law (coined by my father) states that "the plot ALWAYS thickens" and this case failed to become the first known exception to said law.  I had scrubbed in and was watching the procedure.  The attending was saying that it probably wasn't going to turn out having been worth scrubbing for; he correctly pointed out that during a laparoscopic procedure you can generally see as much from halfway across the room as you can with your hands on the operating table.  Less than five minutes after he made that comment, he finally located the uterus among all the abdominal adipose tissue.  It should have been normal-looking.  It was not.  A large gray-white tumor was clearly protruding from the top of the uterus.  Immediately things became more serious.  This was no longer a quick and easy procedure that could be done laparoscopically.  She needed a laparotomy; that is, her belly had to be fully cut open so that we could go searching to see whether the cancer had spread.  Still, though, we were hopeful; if this protruding tumor was an isolated lesion, the patient's odds would still be pretty good.  That optimism lasted an even shorter time than the laparoscopic attempt.  When we opened her abdomen, we found small, nodular tumors everywhere.  Her omentum (a large fat pat in the belly) was liberally spotted with metastatic disease.  The colon appeared to be involved.  And all of a sudden, the once quick and easy case had turned into a nightmare.  Don't know who had to discuss our findings with the patient, but I'm glad it wasn't me.  Please keep her in your prayers tonight; the prognosis is (obviously) pretty poor.

Anyway, that's it for me.  It's time for bed; up at 4 tomorrow to start work at 5.  Yay.  Oh well, at least I have a good team!  Back with more updates in the evening.  Till then, peace and God bless!

SNAFU

Today was kind of a short day, mostly spent in the OR with Dr. Jaja.  Saw a couple of patients with fibroids getting different kinds of myomectomies and one patient undergoing endometrial ablation for heavy bleeding.  I had some reservations about the ablation because of its apparent effects on fertility, but this patient was already infertile and was actually having the procedure for fairly legitimate reasons (including failure of more conservative therapy).  Because there were residents present and fairly little space available, I didn't scrub in; I just watched either on the screens or from whatever angle I had available.  Cases for the day finished about 2:30 or so; I talked with Dr. Jaja for a bit and then headed home.  All in all, my week with him was a good experience that I would recommend, especially in the absence of true pro-life alternatives.

Then came the snafu.  Ob-Gyn here doesn't require night or weekend shifts on the theory that then we have no excuse not to study.  I worked last Saturday because of the program with Dr. Jaja, so my schedule called for me to have tomorrow off.  In a classic case of a genuine favor backfiring, one of my classmates (currently on Gyn-onc) emailed me with instructions from the senior resident regarding who to contact for the start of my gynecologic oncology subrotation.  He cc'ed the email to the intern and AI who are in charge of where and when the students are supposed to meet the team.  Normally, this would be great because it's tough to get all of that information from outside the team; unfortunately, neither he nor the residents were aware that I was supposed to have tomorrow off.  Thus, instead of getting some sleep and meeting with my SP advisor, I will be at Magee at 4:45 tomorrow morning.  Oh well...there's no crying in medicine, right?  Although there might be if I don't get to bed stat; I'm pretty useless when I'm sleepless.  Anyway, back tomorrow with updates from the first day of Gyn-onc.  Till then, peace and God bless!