MDVIP - a different way to approach primary care

Okay, so it has been brought to my attention by various people that I haven't blogged at all this rotation. So, before it is over, I thought I would get a few words in. I am in my second family medicine rotation and loving it. It has been very different from my previous rotation. If you remember my last rotation was on the East side, in the ghetto. The majority of the pts were of a fairly low SES. Their insurance was HMO, and the quality of care was very different, not worse, Dr. Orr still did a great job, but just different. I am currently on the West side, in Summerlin. Dr. Gunter has an MDVIP practice. Most of the pts are very wealthy, and though some may complain, for the most part money is no object (although that has changed since the recession).

Dr. Gunter has a very small practice. He has around 400 pts. He only sees a max of 15 pts a day, and all appts are 30 minutes, unless he is doing an executive physical, that takes 1 hr. The office atmosphere is very laid back and enjoyable. The staff are great. There is a great office dynamic. There are 2 medical assistants Robin (once again, names have been changed to protect the innocent) and Shaniqua. Then you have June at the front desk and Emily, the licensed medical esthetician. Fox News is always playing in the front office on the 32" flat screen. Pts can make themselves a cup of coffee or grab a cold bottle of "Sparklets" water while they wait, although the average wait time is only around 5-10 minutes.

So just in case you don't know how MDVIP works, let me explain. Each pt pays a set fee per year to have unlimited access to the Dr. They still pay their copay when they come in and their insurance is still billed, they are just guaranteed quicker service, shorter wait times, faster appointments, they have the Dr's cell phone and can call for whatever, and they get the 30 minute appointments and a yearly executive physical (very in depth thorough exam).

Okay, so now a little about what I think of the Dr. Gunter's practice. First, I have to say that for years I have had an idea and theory about how I have wanted to practice medicine. I have worked in and around the medical profession for many years and have yet to see anybody practice in the manner that I wish to do so, that is until I saw how Dr. Gunter practiced and his office. I have always thought that going to the doctor should be as much of a calming experience as possible. Dr. Gunter's office provides the ambiance to accomplish just that. There are no tacky drug rep advertisements on the walls, everything is clean and nicely decorated, the colors are cool and calming. Dr. Gunter also isn't one to just prescribe medications for everything and anything, he is open to trying natural alternatives and believes in pushing lifestyle changes before starting the prescription medications. There are many procedures performed in this office, from skin tag removal to circumcision. He also uses various types of alternative medicine - acupuncture and fire cupping. Dr. Gunter is also trained in OMT. These various aspects of his practice, along with the time he is able to spend with his pts really exemplifies the type of medicine that I would like to practice.

Now I do realize that a practice like this is not possible in all settings. It would never work in the HMO setting that I saw in my previous rotation, but it is definitely something that I think could and should be incorporated into the primary care practices. It is a step back to the way primary care used to be, the hands on taking care of the pt. So many Family Drs. just work as "triage specialists," sending their pts to different specialists without treating or using their clinical skills to take care of their pts, in some cases not even touching or examining the pt. That is not how I want to or plan to practice medicine. I want to be hands on. I want to interact with my pts. That is one of the main reasons I became a doctor, for the humanistic interactions that it could provide, for the ability to actually touch and treat pts, to listen and experience life with them.

This month I have seen many things. I will discuss them more in depth in a later post, but I have seen new life, and I have seen those whose lives are ending due to disease. I have felt sorrow as I have become attached to certain pts that have been regulars or those I have seen in the hospital (yes, Dr. Gunter takes care of all of his pts if they go to the hospital and manages their care, if their insurances doesn't require hospitalists), realizing that after this rotation I will probably not see them again. There is part of me that wishes I could stay, continue to be part of their lives and continue to help them.

This has been an excellent rotation, there is not doubt about it. It has been difficult, a long commute every morning and evening, and some days have been pretty long with early morning drives to the hospital, but I have learned so much. Dr. Gunter has been a great teacher, and the office staff have been great. That is one thing that doesn't change, the office dynamics are the same on the West side as they are on the East. You have the same personalities and the same funny interactions. I love it, all of it, and can't wait to one day be part of it on a permanent basis, and not just a drifter, traveling through.

Family Medicine I - Rotation Summary

This was a great rotation. In a lot of ways it was more like Internal Medicine, but Dr. Orr tried to make sure that I was exposed to the pediatric aspect as well. Every Tuesday I would spend the morning with Dr. Yu. In this way I was able to see child care as well. I saw some interesting things, a lot of well child checks, but I saw a case of hand, foot and mouth disease, some childhood obesity, hypertriglyceridemia in a child, and a lot of colds and coughs.

Southwest Medical Associates offers multiple classes for their pts. They have some on sight dieticians that help and assist the pts. Dr. Orr will have you go to some of these classes as well. They have a lot of great information. Definately something that I want to incorporate into my own practice someday. I think that is one of the most important aspects of medicine, pt education. Like the saying goes, "Knowledge is power."

I had my own desk and computer by the nursing staff. It was great to have access to all the pts records and the electronic system that Southwest Medical Associates uses is great. I felt it was very user friendly. I think Dr. Orr is going to have future students take a class to learn how to use it. It is nice to be able to view the pts lab results and past visits before the pt comes in so you can better become aware of what the pt might need.

There is a staff lounge with microwaves and a refrigerator for lunches. Occasionally there will be drug reps that will bring in lunches. Those are usually pretty good. There are also some pretty good Mexican restaurants around from what Dr. Inocencio says. I tried out one of them, if you get a chance to go to Los Toritos, you have to try the Horchata (a drink) and the Sope (a corn tortilla type thing, but not really, hard to explain). Make sure you take plenty of water. There isn't purified water anywhere except the vending machines, and the tap water is awful.

Dr. Richard Orr is a great Dr. I learned a lot from him. He is eager to teach and very helpful. He never makes you feel stupid regardless of the question, he understands that you are still learning and does his best to make sure that you learn something. He doesn't assign you topics to study, but allows you to take something that you found interesting that day and focus on it for your studying. I saw many different things, of course the expected things: HTN, hyperlipidemia, diabetes mellitus, asthma, and COPD, but I also saw a pt with early onset Huntington's Dz, a women with ALS (Lou Gehrig's Dz), a woman with goiter and a menangioma (brain tumor), and a man with CML and squamous cell carcinoma of the lungs. I learned about pts who are proactive in their own care and listen to you, and then about those that are non-compliant and don't. Of the many things I learned this rotation I think Dr. Orr taught me the art of practicing medicine. I am grateful for what I have learned from him.

I can honestly say that I loved this rotation. The Drs and staff were all great, very helpful and very kind. It was a great environment to work in and learn. The dynamics of the office are enjoyable. The back office staff and their jokes. It reminded me of the office I worked at as a medical assistant. It brought back lots of memories, and further strengthened my desire to pursue family medicine. I loved being able to spend time with pts. Sure it wasn't a lot, but there was interaction, there was continuity. I saw some pts more than once during the month. I hope that all other Touro students enjoy this rotation as much as I did. Good luck to whoever is next and have fun.

Never a dull moment

Okay, so I have today off. I went in and found that my Dr. was sick, so they told me to go study. I spent the morning studying diabetes mellitus and its treatments, if your interested ask me sometime and we'll see how much I remember. :) I just finished lunch and thought I would update my blog. I've had a few interesting and somewhat humorous things happen lately.

Captain Ajo (garlic in Spanish) came in last week. Wow, I like garlic, but this guy could not seem to get enough of it. I guess he eats 12 cloves a day; apparently he has scaled it back from 24. This gentleman stunk. My wife always says she can tell when I have had some meal with garlic in it, now I know what she means, I pray that I don't smell that bad (I doubt it). When the pt changed rooms from the triage room I was gagging in the hall. Just walking by the room he was in stung my nose. Dr. Orr's nurse was trying her hardest not to vomit. Wow, you would think somebody would have said something to him. Why does the doctor have to be the one to tell people these things? My Dr. informed the pt that he stunk, really, he didn't hold back, he gave it to him straight. The man was surprised, he said that nobody had said anything before, I highly doubt that. Anyway, he said he would try to cut it back to 3 or 4, the Dr. told him he really needed to, for the sake of all those that had to be around him. One of the older nurses said that it was an old wives tale that garlic would protect you from Syphilis. Not sure about the scientific backing on that claim, but at least he won't be bothered by any vampires this Halloween.

*Okay, now for a disclaimer. I'm going to mention S**. Just to warn anyone that might want to stop reading, nothing graphic of course, but just mention it, and maybe some body parts.

The other day a gentleman came in, he was in his 60's. Nice guy, just in for a follow up, at least that is what he told the nurse, what he really wanted was an Rx for Viagra. I had done the H & P (history and physical) and consulted with the doctor as to the pts treatments and complaints. The doctor and I had gone back in with the pt. This pt happened to be on a medication for his enlarged prostate that can't be taken with Viagra, anyway, he decided he would rather have the Viagra and didn't care about the enlarged prostate. The visit was over and the Dr had commented on how the pt had lost some weight (about 40 lbs) as he was preparing to exit the room. The pt quickly apologized to his wife for the comment he was about to make and matter of factly stated: "Well you know doc, it should be a wake up call for any man when he looks down and can't see his penis anymore." We exited quickly and I tried not to burst into laughter. But he does have a point. Watch your weight guys.

That same day there was a couple that came into the office. He was 84 and was recovering from a recently broken pelvis. His wife was 75, and drove into the office on her little scooter. The Dr. had addressed their concerns, that is almost addressed all their concerns. When he asked if there was anything else the older gentleman stated that his sex life wasn't too hot right now. His wife quickly agreed and stated that he definitely needed some help. Now there were a couple of thoughts that ran through my mind, first was: GROSS!! I did not need to know that. The second was: how refreshing to know that even at 84 and 75 some people are still attempting to have a healthy sex life, and why shouldn't they, right?! The third and final thought: is it safe for an 84 year old man to be taking an erectile dysfunction (ED) medication? The Dr. informed me that as long as he wasn't taking any of the meds that interact negatively with the ED medication, he was okay prescribing the meds. I guess it was just kind of a shock to me, I mean, really, hear from people the same age as your grandparents that they are having sex, not something anyone wants to think about, but hey, such is life and I guess we just have to learn to move past the shock factor of some statements.

Finally, I had another experience, but this one involved a mother and her 6 year old son. Every Tuesday morning I go upstairs to the Pediatric office and work with one of the pediatricians so I can get the exposure to the pediatric side of Family Medicine. The other day a mother brought her son in for a cold as well as a well child check. The Dr. had finished the exam (isn't it interesting how all of these things happen just as you are trying to end the encounter and leave the room?) and the mother stated that she had a concern, that her little boys penis was too small. I was terrified. That poor child, can you imagine being six (okay, maybe you wouldn't care) and having your mom tell the Dr. that you had a small wiener? Well, the Dr. informed the mother that it was a perfectly normal size, it was just that the little boy was fat. Okay, not really sure which one is worse, you have a small wiener, or no, you are just fat. Now the mother and child were Hispanic, so the doctor was trying her best to explain this in Spanish. I think some things may have gotten lost in translation. Anyway, the Dr. then proceeded to show the mother that her son was normal, you just had to push the fat out of the way. Wow, I hope that poor child isn't scared for life. But then again, maybe it will be for the better, the mother might actually make the kid exercise, and the kid might become a little motivated himself. I tried to explain to the mother after the importance of a healthy diet and exerise. Hopefully they got it.

Okay, so that is it for this post. Some rather interesting people and off the wall experiences. I think I have learned one important thing. Never ask the pt at the end of the visit if there is anything else, you never know what they are going to say, or what you will have to try to explain or do.

Patients - a learning experience

I had some interesting experiences this past week, and not all of a medical nature. I have learned some things and my eyes were opened. I learned these things from patients. These experiences have caused me to think: who is truly being helped? Are we helping them, or are they really the ones helping us? Where would we be without them, the pt?

A quick preface. I love people, always have, love to be around them, talk with them, and interact with them. If I could sit in the room with a pt for 30 minutes just talking about regular random things I would. I love learning from them and through their lives and experiences. That is part of why I wanted to become a doctor. I wanted to help people, but I also wanted to be part of their lives in a way that most people don’t have the opportunity to do. There is so much we can learn from others, regardless of what positions they occupy in this world. These lessons are learned through viewing people’s actions or by listening, really listening to people’s words.

Experience #1: On Wednesday, two interesting people came into the office, and with them, a very special woman. These two pts, a brother and a sister were both deaf and blind. They are both in their sixties. Their mother took care of them, but a couple of years before her death an angel stepped in. A women who was not a blood relative, but felt compelled to help. This woman took over their care, taking them into her own house, giving their mother a well deserved rest from her many years of hard work. When their mother died, this woman continued to care for them. They currently live in the home their mother owned. This saintly woman goes over daily to administer their medications and prepare them a meal. She communicates with them as Anne Sullivan communicated with Helen Keller. In addition to the responsibility of caring for two deaf-blind people, she and her husband have eight children, some of them theirs and others foster. Sitting in the exam room and watching this woman communicate with these two people I was taken by the love and care that she showed them. Although noticeably tired she communicated with these pts with love and tenderness. When complemented for her service brushed it off as if it were nothing; but that is far from the reality of what she does. Without her, these two would live in complete darkness and silence, with no way of communicating. Through her actions this woman showed me this week what it truly means to serve.

Experience #2: Yesterday morning I had the privilege of meeting a wonderful couple, they had been married for over 50 years, had 6 children, and 8 grandchildren. As I went into the room to talk to this pt and find out her symptoms I made small talk, just trying to get to know them a little. Before me sat a woman with Parkinson’s, in her late 70’s, hunched over, her age definitely showing. She looked much older than her 79 yrs, but when her age came up I commented that she looked good for 79. Her husband’s response brought a smile to my face. “Your damn right she looks good for 79, she looks great.” I looked at them both after that statement and saw a smile, a look, a brief glance pass between them; something that had the power to portray in a fraction of a second what their 50+ years together had meant to them both. Were they easy years? I don’t know, probably not, but I do know that through the good and the bad it had all been worth it to that point. That is what that one glance stated, his words a testament of his continued love. That is love, we too often forget why we originally “fell in love” with that one person. We don’t want to work through the hard times, we see beauty fade after years of work and hard times and decide that a newer model, something different, would be better, and it is all thrown away. Why? Could it ever be better than what I described above? I say no. Fifty years from now I want to be sitting across from my wife, our good looks will be gone, replaced with wrinkles and grey, but to each other we will still possess that beauty, an inner beauty and strength that we have cultivated together through the good and the bad times, and I will say to anyone that brings it up: “Your damn right she looks good for 79, she looks great;” we will look at each other, that glance and smile will pass between us, and we will know that we have made it to this point, and that every moment has been worth it, the good and the bad.

So although I saw around one hundred pts this past week, was able to cut off some skin tags, assist in a toenail removal, and learned various things about the practice of medicine. I also learned some wonderful things about life, and about what our purpose is in this world. What it really comes down to is service, pure unselfish service, no motives and not strings attached, and love. Not to sound corny, but isn’t that what medicine is really about; we serve and to some degree we love our pts, some more than others, but regardless there is some level of love, that compassion within each of us that moves and compels us to act and to serve.

Family Medicine - Oh the DRAMA!

Well, I'm 2 weeks into my family medicine rotation and I'm loving it. I love it all the crazy office dynamics, the crazy patients, and the crazy experiences. There is a dynamic in a Family Med office that I haven't found anywhere else yet. It is great. Maybe it has something to do with the fact that I spent 2 years as a medical assistant and can totally relate to the experiences. I feel like I'm home. Maybe that sounds a little corny, but it is so true. I have missed the office banter, the inside jokes, and most of all the crazy, and I mean crazy patients.

So I am currently rotating at Southwest Medical Associates. It is a large multi-specialty group. The office that I'm in has Adult medicine, pediatrics, and OB/GYN. I'm in the adult medicine group. There are probably around 20 doctors in this one building. It is a nice place. Since the Dr. I'm with only does adults, he has me go up with one of the Pediatricians once a week for a couple hours.

Okay, so about the area. Let just say that it has been referred to as "the projects" by several of the employees. There was a car parked outside one of the office windows. Some kids broke into the car during the middle of the day while the Dr was in the room with a pt. They smashed out the windows and took off. Well, that happened before I got there, but the car just stayed there, nobody moved it or did anything. Finally, last week the cops came by and the car was towed off. To give the area some credit, Dr. Orr said if it had been Detroit, where he grew up, there would have only been a frame left out there. It is also a little disconcerting to have a sign on the sliding doors that reads "Please leave your weapons in your cars." I guess one pt did bring a gun in last month. He insisted that the nurse take off 2 lbs for the gun in his pocket. Crazy people.

I haven't had anything that exciting happen yet, but have had some interesting patients. I had one lady inform me that she had been doing "stretches" to prepare for her GYN appointment, since she hadn't been with a man in years. Okay, that was a little too much info, didn't need to know that mam, really. Not sure I quite know what she was referring to, and don't think I want to know. I have had the opportunity to perform 5 DREs (digital rectal exams). Let me tell you, that is a good time. NOT!!! Okay, very gross, especially when the reason for the exam is because the poor guys either have hemorrhoids, or are having problems with leaking. Not fun to get old. I'm sure a couple of the guys won't be back, they were two fairly young Hispanic guys. The Dr. checked them out and then told me to put on some gloves, so before they could pull their pants up they were violated by another finger. Yeah, they seemed a little embarrassed as they left, not sure if they will be back, but hey guys, thanks for the learning experience. :) The funniest one so far was a Hispanic gentleman that told me he wanted his prostate checked. I had been talking to him in Spanish, but apparently didn't explain things well enough concerning the exam, because when I told him to drop his pants for the DRE he about flew out the door. I have never seen a man get so upset and uncomfortable. It was kind of amusing. In explaining that you need the DRE and the blood test for it to be a complete accurate portrayal of the prostate he declined the DRE for the time being. LOL. Oh if you could have seen his face.

Something not necessarily funny, but sad, today I saw a 3 yr old that twice the size of my 3 yr old. Can you believe it, Chase is 35 lbs, he is a good sized kid, tall for his age, not small by any means. Well, this kid was shorter than Chase and weighed in at 71 lbs. Crazy huh?! Poor kid, he was so cute though, with his round face, chubby fingers, and red hair, how could he be anything but cute (wink). Unfortunately the kid has reflux issues at 3 not to mention triglycerides of 300 (normal is less than 150). This kid is in for a rough life, and then try to explain to his mother that it isn't a good thing that he is that big. She said he likes oatmeal and eats it twice a day (two bowls of a day? are you kidding me), apparently "He just loves that peaches and cream kind." Yeah, not quite the same as the good old fashioned oatmeal, and yeah, he definitely doesn't need 2 bowls.

Well there are a few of my experiences so far. It is fun to see Juanita (names have been changed to protect the innocent), Peter, and Angie go back and forth giving each other a hard time. They sit back by my desk. Oh yeah, I forgot to mention that I have my own desk. Cool huh!!! So I'm going to sign off for right now, but just have to say again: I love family medicine!!!

General Surgery II Rotation Summary

Okay, so I have finished two months of rotations and have taken my first exam. All in all I think I have done okay, at least I'm not any worse for wear, and I have actually learned a few things. I was even surprised in my exam today to actually know some of the answers. :)

So this is the summary of my latest rotation. Plastic Surgery with Dr. Carl Williams. It was a good experience. We were a little slow, sometimes really slow, but that is in the stages of changing. He will be moving to Valley soon and so students will be able to do a lot more. Here is an outline of an average week.

Monday's were surgery days at Seven Hills Surgical Center. Make sure you take a packet with you or you won't be able to observe. It isn't listed as a place that you need to badge, but Dr. Williams spends 2 days a week there. It is a very nice facility. Privately owned, as Dr. Williams said it "the Ritz-Carlton of surgery centers." Very nice, and wonderful staff. Mondays are a hand surgery day and they start at 9:30. No need to be there early, just be there on time. They have their own scrubs that you can change into. It is then your job to do the H & P on the pts undergoing surgery that day. Dr. Williams will show up and mark the hand or arm. You are allowed to scrub in at Seven Hills, but Dr. Williams has his own assistant who aids in the operations, all you really do is look over his shoulder, ask questions, and listen to what he has to say. You will also have lunch on these days. The Dr or surgery center (not sure which one) buys the students lunch. Mondays it comes from the Spicy Pickle, a good sandwich place. After lunch you head to the office and see pts for the afternoon. Usually their aren't a lot on Mondays.

*Okay, so as far as seeing pts goes, you will observe for a couple people and then Rob, the Dr's assistant will have you do most of it. There are forms in each chart that are to be filled out. You just ask the questions. It is pretty basic. Not sure if it helps prepare us for the physical exam portion of next years board exam, but at least you get some practice asking questions, even if they do all have to do with pretty much the same thing.

Tuesdays are another Seven Hills day, but that is the cosmetic surgery day. Same thing as before, same time, same routine, but this time Dr. Williams nurse Sandy comes in to assist. She does all the cosmetic consults in the office (you won't be in on those) and then assists on the surgeries, as well as taking before and after pictures of whatever is being done. Lunch is El Pollo Loco and then onto the office to see pts again.

Wednesday is another hand surgery day at North Vista Hospital. Badging was a pain there, I never got my actual badge, but it really doesn't matter. I don't know why they even ask for the packet and scrub class certification; you aren't allowed to do anything, not even scrub in, so it makes it very difficult to see and know what is going on. Just ask lots of questions regarding what he is doing. Dr. Williams is great at explaining and teaching if you ask. On Tuesday you will be given a packet by Judi (she is scheduling and authorization at the office), this packet contains all the info on the pts having surgery that day, their release forms as well as MRI results and other things that Dr. might want to see. You are in charge of making sure it gets there and into the hands of the Dr. Surgery starts at 7:30 am, so be there around 7. They also have their own scrubs that they have you wear. When you get there, change and do the H & P on the first pt. Dr. Williams will get there around 7:30 or 8:00. He will mark the pt and then off you go for breakfast. He takes you into the Dr's Lounge. Technically we aren't allowed in there, only Dr's, but Dr. Williams doesn't care, he said in the beginning that the one thing that wouldn't happen during my rotation with him is that I wouldn't go hungry. After breakfast we all go to surgery, you observe and then you have lunch in the Dr's Lounge. In the afternoon there are 2 things that can happen, either you stay at North Vista and see pts at the satellite office, or you go back to the Anthem office and see pts there. It switches every week. Wednesday night Dr. Williams is on trauma call at UMC, if he gets any cases he will call you. I never got a call, but oh well, I got my sleep. :)

Thursday is an office day, all day. You start at 9:30 usually, but it might be later depending on the schedule. You will see a lot of trauma pts, and a lot of follow ups from trauma. It is cool to see the different stages of recovery from the various surgeries, especially since we aren't there long enough to follow one pt all the way through recovery. Some of these pts follow up for up to a year depending on the trauma or surgery that they had.

Fridays are hand surgery at UMC. Unfortunately I only had one day there, my very last day of rotations. UMC is great because you can actually do stuff. Dr. Williams will teach you to suture. I was able to place a pin in a guys hand. It is a great teaching environment. You will also have breakfast and lunch there in the Dr's Lounge (he will have you take off your badge so they don't know you are a student, they are really strict there, even the residents aren't allowed to eat there). After surgery you are done for the day, no office hrs on Fridays.

So that was a typical week. I think I learned quite a bit. Dr. Williams was great at talking about real world stuff as well, having a private practice and what comes with that. Health insurance and how they worked. Did you know that when an insurance company authorizes a procedure it doesn't mean they will actually pay you for it? Yeah, crazy huh, he said that around 1 in 10 operations won't be paid for.

Oh, you wear scrubs every day. No white coat, and they introduce you to most people as a resident, otherwise some of the high end clients that he has wouldn't let you in the room. It is a nice work environment, kind of a family thing. Rob (the hand assistant), his wife Candi works in the front office. Sandi (the nurse) is Rob's mom, and Judi, well there is no relation. :) They are all very nice and fun to work with. I ended up observing 18 different operations, only 3 of which were cosmetic. Most were hand, carpel tunnel releases, ganglion cyst removals, nothing super exciting, although I did see the Dr. sew the median nerve back together on a pt, that was cool, and then my UMC day was great. If you have Dr. Williams, I hope you enjoy him, oh, and tell him I said hi! :)

Surgery @ UMC

*Disclaimer: there may be some information that might be considered gross and might make some a little squeamish.

Okay, so I know I just posted yesterday, but I wanted to talk a little bit about the surgeries I assisted with today at UMC. Dr. Williams goes to UMC on Fridays. Unfortunately for me, this was the only Friday this month that he had anything scheduled there. I was able to be first assist for 4 different surgeries, place a pin, and do some stitches. So here is the run down of what happened today.

I got there early, around 7:00. Dr. Williams has the student take the pre-op H & P (history and physical). I wanted to get it done by 7:30 (when the first pt was supposed to go back for surgery). Well, I was working on it when Dr. Williams came in. I was surprised to see him because he is usually a little late. Anyway, we got it done and were ready to go and we waited, and waited, and waited, and waited. Turns out the 1st pt of the day didn't want the anesthesiologists that they have at UMC, so we had a guy from a private practice coming apparently, nobody told him that the surgery had been changed from 8:30 am to 7:30 am. So we waited an hour for him to show up, putting us and everybody else slightly behind. :)

The first surgery was a CTR (carpal tunnel release) along with a cubital tunnel release (elbow area). These two procedures free up the median and the ulnar nerves respectively. This pt was having weakness in the arms and pain and tingling in the ring and little fingers. It was a cool procedure. I've seen probably 5 or 6 of these done this past month. The cubital tunnel release requires that they shave off part of the bone that surrounds the ulnar nerve (the medial epicondyl). This helps free things up so the nerve can move freely. I was able to help suture the pts carpal tunnel incision.

Surgery #2 was the removal of osteophytes (bone spurs) on the 2nd, 3rd, and 4th digits at the DIP joint (joint right below the fingernail). This required some rather large incisions shaped like a capital Y. The skin was pealed back and then an instrument, kind of like pliers, was used to removed the osteophytes. Dr. Williams let me suture the incision on the ring finger. Pretty cool. It took me awhile, he finished his two in the time it took me to finish my one but oh well, he is very patient and a good teacher.

*So the picture is not from the actual surgery, just something to give you an idea of what we did, there was only one pin and wire surrounding the bone.

Number 3 was a young male that claimed he had broken his hand 2 weeks earlier. The X-rays showed an old fracture of the 3rd metacarpal bone (the bone in the palm of the hand) and it had a fragment of bone that was joined at the top of the bone, but pointing out as it moved towards the bottom. The doctor made an incision, located the old break and re broke the bone so that he could put the part that was sticking out back in line with the rest of the bone. He then wired it together. The next part was the exciting part; the placement of the pin. Dr. Williams let me do it, he of course guided me, but I was operating the drill. The X-rays taken after the placement of the pin showed that everything was in alignment. Pretty good for my first time. Okay, so it wasn't all me, definitely couldn't have done it by myself, but it was still a great experience. After Dr. Williams closed the inside, I placed the interrupted sutures along the outside.

The 4th surgery was the removal of a sebaceous cyst located on a pts face. It had been there for about 2 years and was the size of a golf ball, located lateral and inferior to the eye. I can't believe it took the pt this long to get the thing removed. I just watched this one, but yeah, sebaceous cysts are really gross, especially when they are punctured. Two years worth of oil and pus (looked a lot like cottage cheese) came out. Sorry for the comparison, hope it doesn't give anybody an aversion to cottage cheese. This pt was closed up and a drain was placed.

Okay, so that was it for the day. Really a great day. I wish that I had more opportunities to operate at UMC with Dr. Williams. He is a great teacher and very patient. He told me (I'm going to toot my own horn here) that I was better than probably 90% of the students that he has come in and suture. Thank you, thank you very much. I can hear the applause. :) He asked me if I had sutured before and I informed him that my dad was a veterinarian and had taught me a little and let me practice on some dogs he had operated on. He said my technique was great and he could tell that I had learned how to handle the instruments. He said my dad must be a good surgeon. Good job DAD!!!! Praise from one of the best hand surgeons in the west (you rock). So that was it. I will give a synopsis of the entire rotation next week, but there was my UMC experience. Hope everybody else has as great an experience as I did.