I (Heart) Rural Medicine

In the last 48h have included having the opportunity to:

-catch a baby
-cut a piece of glass out of someone's face (and then stitch them up afterward)
-surgically assist with fusing toes, replacing hips, replacing knees
-perform a D&C
-assist with a hysterectomy
-sew up knife wounds
-assess / treat / discharge about 75 emergency patients
-learn how to insert an IUD

Despite the exceedingly damp climate my hands are cracking from so much handwashing, I'm surviving solely on t.v. dinners and instant soups, clean underwear is becoming a scarce commodity, and I've spent every day (except one) in the hospital since my arrival. And I couldn't be happier.

My days are so full and varied, with such fantastic teaching from the docs here. It's hard to sleep at night, completely wired and excited by each day's events. I feel so fortunate to be here. I'm starting to believe that saying about how "there are teaching hospitals and then there are learning hospitals". Say what you will about rural medicine...but my experience is that people working in remote areas have half the egos and double the desire to teach.

I've been spending a lot of my retractor-holding and trying-to-sleep time thinking about the (soon arriving) residency application process. Today I truly felt like a few things have started to crystallize in my mind about what I want to pursue...

As always it is a work in progress, but I think that will have to be a post for another day.

In the meantime, check out my new O.R clogs while I try to get some well deserved sleep.

Yes, yes I did.

Hard Mattress

After a somewhat lengthy orthopedic surgery where I had been holding a foot / leg up off the table, Dr. Boots handed over the suture material and told me to get to work.

Me:

Umm...should I come around to the other side of the table?

Dr. Boots:

No, sweetheart just get to work, this man's got a bloody tourniquet on! We don't have time for dancing around. Put in some mattress sutures. 

(Some of you might scoff at the fact that I haven't mastered the mattress suture. As a potentially aspiring surgeon I maybe should be able to do them in my sleep, however, I spent most of my time in general surgery trying to perfect my sub-cue stitches and hand-tying. Bad medical student, BAD!)

And now I have.

And they were a thing of beauty. All two of them. Damn you arthroscopy and your tiny wounds!

Dr. Boots:

There, that wasn't so bad now. No need for all the shivering and shaking. You know my 17 year old daughter can do mattress sutures, no problem. She taught herself.

(Surgical Drape) Curtain Falls. 

[For the record...my hands were shaking because my forearm muscles were maxed out from assisting...I swear! I should also add, Dr. Boots is amazing and kind of like the slightly-unimpressed-but-fantastic-teacher orthopedic-surgeon-father I never had. Above example illustrates the way we communicate. Me, hopeless rube in ortho...him ortho king. Get it?]

Surgical Pearl: Nutrition

Today the locum pediatric orthopod took me down to the x-ray department to look at some films, on our way out he stopped at their desk and poached some chocolate. He clearly saw my judging questioning gaze (I have firm beliefs that you ought to contribute to the trough you graze from).

"Look, when you're a surgical resident you learn to get calories from any source available. It's an old habit. You find every patient fridge that is stocked with ensure or crackers...this hospital is great because the recovery room fridge has cheese. Cheese will be where you get your fluids from."

Residency: when you begin to see cheese as hydrating nourishment.

Surgical Field Trip

Headed for the hills today for a surgical assist field trip. M.C took me with him to the wild and wooly west coast for an operating theater day in one of the remote hospitals.

I have Monday's off (from GP) but was more than happy to spring out of bed at 0545h, knowing that I'd have the chance to be first assist and 'camera woman' for all the cases today.

And indeed, it was well worth it. Worked a lot on my sub-cue suturing skills and scope handling. Lots of neck craning and nervous sweat. So. Much. Fun.

I really cannot pretend to be aloof about this whole surgery thing. Pretty soon I'll stop sheepishly mumbling and toeing the floor when people ask me what I want to be when I grow up. Not today, but pretty soon.

OB or not OB?

We have been up to our eyeballs in pelvic floor muscles lately as our last few cases have been covering pregnancy, babies, ambiguous genitalia, labor and delivery. 

Now normally I am not a fan about learning the differences between the somatic, autonomic, and visceral nerve supply to muscles, but I have to admit, knowing the practical applications for managing labor pain has made this memorization a bit more interesting. I am sure it is because I love procedural skills and can't wait to do my first nerve block, epidural, lumbar puncture, and perineal repair. I started thinking about all the hands on work that OB/GYN's do and then having thoughts that were alien to me until now ..."obstetrics? maybe?"

Truthfully, back in the days when I was an annoyingly-militant-vegan-self-righteous-naive-hippie I seriously considered midwifery (not to say that midwives are those things, I am just elaborating on a phase I went through in my early twenties). I even took my doula training and looked into various programs across the country in midwifery. The only thing that really held me back from pursing this career was the fact that Canada has some ridiculously archaic and paternalistic conservative attitudes regarding who ought to be bringing babies into the world. Depending on what province you live in it can be a seriously uphill battle to create a career for yourself as a midwife--that is, no hospital privileges, being shut out by the medical community, lacking public subsidies, and having to conduct only home births without OB back-up. I just wasn't up for the challenge, I guess. 

Fast forward to medical school where I continued to reject the Western approach to birth, until very recently.

We had an OB/GYN lecture us this week. She was Irish but had spent 10 years specializing in the US in high risk delivery and maternal/fetal medicine. Her lecture was delivered in a soft spoken but direct and powerful way. About half way through she stopped on the slide shown to the left, and said,

"I have always wanted to be a part of this event in people's lives. Even when it is cold, dark, and in the middle of the night I love to get up and head to the hospital knowing that this is what I get to be involved in. When the babies start looking the same and I am not thrilled to be there, I am going to quit. But right now, I feel nothing but privilege for being invited to take part in this pivotal moment in people's lives".

She apologized for how hokey it sounded but I felt that it was quite lovely, to hear someone speak so passionately and honestly about their career choice. I suppose it is what we are all striving for when we choose our future specialty, what are we passionate about? Am I going to love living in the O.R, or intubating patients in a helicopter, or prescribing chemotherapy regimes? It is so hard to know at this stage having only seen as sliver of the health care system. But when you hear someone speak from the heart, and they clearly do love their job, it makes you wonder...could I love constantly being sprayed with amniotic fluid and having only female patients for the rest of my life?

Maybe!

OB/GYN Pros:                                                                     OB/GYN Cons:
-lots of healthy patients                                                          -on call, forever and ever, amen
-plenty of hands-on procedures                                              -bodily fluid exposure extravaganza
-O.R from time to time                                                           -bad outcomes are very bad
-emergency situations*                                                           -only female pts
-many good outcomes                                                             -continuity of care
-continuity of care                                                                   -highly litigious
-many happy/excited patients                                                 -crazy women with 5 page birth plans
-immediate results                                                                  -having patient load
-the whole 'miracle of birth' thing                                          -the training

If nothing else, I am trying to keep my mind open to the possibility of areas that I hadn't considered. I know how most medical students start rocking in the fetal position (pun intended) when you mention their OB/GYN rotation but...who knows? Maybe I will be one of the lucky ones and will actually enjoy labor and delivery!

Or maybe I'll just end up with countless pages of blog fodder.

Either way, win!

*I know that sounds twisted...but I am wired to enjoy emergencies for some reason. I blame my mother for not breast feeding me long enough. (Hi Mom!) 


   

Summer Placements--Yipeeee!

Vista from the road near Dingle.

The school has just released our placements for 1st semester of third year. I am very excited as I found out that I will be rotating first through surgery in Tralee, County Kerry.

So, surgery is the thing I am most looking forward to next year as it will allow the greatest leap from my experiences as a nurse...and not to mention the fact that I adored every minute in the O.R this summer!!

I had originally asked to be placed in the Big Regional Hospital but then the placements coordinator emailed me and asked if I'd consider going to Kerry for the entire year. I had put Killarney (near Tralee) as my preference for GP placement in 2nd semester so moving for the entire year made sense.

I hummed and hawed for the evening, drank two glasses of wine, called a few of my Irish pals for advice, then responded "yes" before wondering what I was getting myself into.

The hospitals in Tralee are much smaller than Big Regional but the location is one giant beautiful wide open space of mountains and ocean. And I will be close to Killarney and Dingle. For those of you who've been to the area you'll be able to appreciate why I am so excited to be a 30 minute drive from the Ring of Kerry.

Dingle Harbor

The other interesting thing is that there is only going to be one person from my class at the same hospital as me, and we'll be on opposite rotations (he'll be in med while I am in surg). He's actually one of the most down to earth and sincere lads in the class--plus he's a fellow West Coast Canadian! So having a bit of company (of the quality variety) will be good. My heart is always in smaller centers, I adore rural health care and I think for electives it will be nice to be as far away as possible from some of the competitive knobs in my class.

Fingers crossed I land some decent preceptors...

Hip Replacements and Baby Catching

This past week was amazing.

Some of the highlights.

I delivered my first baby! Yes. It turns out if you harass the maternity nurses and docs enough they will call you up to catch one. I had witnessed a few during the summer but it wasn't until the day before my birthday that I got to catch my first one (thanks Doc R!) Baby Jessica was 9 lbs 4 oz, slippery, pink, screaming and born with a head of dark curls.

I was so excited in those last few pushes I had to clasp my hands together in order to keep them from inadvertently just reaching in there and taking the babe out or patting the perineum with anticipation. Doc R and I had gone through the steps verbally ahead of time but I hadn't really thought of what I was meant to do once the slippery, heavy, squirming baby was actually in my arms! I think I was giggling and cheering and almost (sorta) tearing up and then thought-- "er...do I put her down or clamp the cord or...ack!" It was a crazy wonderful blur and flurry of activity, Doc R helped me from there, "yes...just set the baby down now", "oh, right".

Yes she did give me permission to post this photo of her.

That afternoon I got to scrub in for a great toe amputation. It actually amazed me at how simple and slick it is to remove a toe. The thing really didn't give up much of a fight at all, just a couple of swipes with the 'ol scalpel and, thunk! It's in the bin. For some reason I just assumed that everything in the body was really anchored down. Meshed together, tightly woven. I suppose that I've always thought that because in order to have survived the sabre toothed tigers, bears, falls, wars, famine, the body must be a very study structure. But as I am seeing more and more in the operating room, it really isn't.

The next day my colleagues kindly let me spend most of the day shift (which was supposed to be spent working in the  emergency department) scrubbed in on several orthopedic surgeries. Ok, let me just say now, I take back EVERYTHING I ever said about orthopedics.

How I could never do it. 

How I could never stand to watch such brutal surgeries. 

Oh how very off the mark I was. 

Let's just say, tendon harvesting for ACL repairs is a thing of beauty. I was actually operating the arthroscope for that one. Hello that is not an easy task. When you are staring at a large screen tv it is difficult to immediately appreciate that moving the scope 1mm actually turns your field of view to a completely different scene. I could feel the sweat running between my shoulder blades and down the backs of my knees, 

just don't screw up

don't lose what he's trying to look at

don't pull the scope out by accident. 

Yeah, I did all three. Considering the fits of rage that I'd seen come from Dr. S I was expecting him to wrap the scope around my neck and throttle me with it. But to my surprise he only called me a 'useless assistant' a couple of times and commented on how much I was slowing him down once! He also yelled pointed out that holding the scope for the first time was no excuse for not doing a good job. I was in bone-chip, bloody, tendon harvesting heaven so it didn't even bother me. He let me pull the finished graph through the hole to where it was anchored. Pretty amazing actually. 

Other thoughts from the day included, 

Wow! the plantar fascia is REALLY thick and white!

I can't believe that a hammer and chisel were just used to crack open that calcaneus! 

Exposed muscle really is a thing of beauty!

I think I might faint from hunger and sleep deprivation soon!

Hey. I didn't say they were deep thoughts. 

There was also a theme party--70's due to the decor in my living room. It was a combined triple birthday party/retirement from nursing for ABB party. 

Things really took off when both Karaoke and Dance Dance Revolution showed up. 

Yes I am wearing a giant peace sign bindi. Thanks for asking.

There was also a beautiful 15km hike one day, some c-sections, entertaining shifts in the emergency department, dinner on a cruise ship, the move into a new (wicked) house, a meteor shower, and possibly a hang-over somewhere in there as well.

Two shifts left as a nurse. So many memories rising to the surface. Almost exactly 7 years to the day that I graduated. 

Cartoon and OR Theme

The recent post by Doctor Grumpy reminded me of this clip my friend Aaron sent me a couple of weeks ago. It is particularly pertinent given my recent activities.

Rae (fellow emerg RN) and I gave each other report in these voices today and drove everyone insane. Does make hand-off much more entertaining mind you...

Enjoy!

Fun in the OR

Got to scrub in today for three neck surgeries and one ortho repair of a fractured ankle.

The Albinoblackbear tastes surgery and LIKES it!!

Oh dear.

More on that later. Right now I am heading back (after a quick meal and 20min nap) to work a 12h night shift. Gonna be a long long night.

And... *drum roll please*

I PASSED FIRST YEAR! Woooohhoooooo!

(It is pass/fail so I am assuming "P" is for "passed").