I must confess that I love watching medical dramas on TV. Most physicians hate them because they exaggerate the way medicine is really practiced, but I think they're just plain entertaining and I've actually learned a thing or two from them.
But one thing does bother me. Every other patient who goes to the ER gets a chest tube. And it always happens the same way. Someone shouts, "we need a chest tube in here STAT!" A junior resident/student tries to insert the chest tube and fails. The senior resident angrily pushes him aside and easily slides in the chest tube. There's a gush of air and a change in the cadence of the beeping monitors. The patient coughs and sits straight up, clearly revived. Someone says, "good work, people". Two doctors start making out and then 3 episodes later, one has amnesia.
In my 5 years as a medical student and intern, I have never witnessed a STAT chest tube insertion in the ER, but I guess it makes for good drama on TV.
I thought I would explain exactly how breathing mechanics work and why chest tubes need to be inserted.
There are 2 fundamental structures involved in taking a breath. The lungs and the chest cavity. Lungs are really just a bag of air, like a balloon. It has blood vessels and some other tissue, but it mainly just holds air. The chest cavity (comprised of the rib cage and diaphragm) is a rigid scaffolding which protects the lungs and acts as an anchor for the muscles which allow breathing to occur.
The entire system can be thought of as a balloon within a balloon (the inside balloon is the lungs and the outside balloon is the chest cavity). Because the chest cavity has ribs, it is actually rigid so that it cannot really expand/contract as much as the inside balloon can. But the chest cavity does have a diaphragm.
The diaphragm is a muscle which can make the chest cavity bigger and smaller depending on how contracted it is. When you take a breath, the diaphragm contracts downward and expands the chest cavity. Because the rest of the chest cavity is rigid (because of the ribs), and the lungs are very elastic, air is sucked into the lungs. The lungs are now expanded with air.
Exhaling is mostly a passive process. The diaphragm relaxes, making the chest cavity smaller and allowing the lungs to blow air gently out.
That's all it takes to breath.
Chest tubes come into play when the lung collapses (in medical terms, a pneumothorax).
In real life, the lungs and chest cavity are not stuck together. There is actually a space separating the two (called the pleural space). But functionally, the lungs and chest cavity are stuck together because this space is usually sealed under a negative "sucking" pressure. So when your chest cavity pulls outward (expands), it pulls on the
pleural space, which in turn pulls on the lungs, which expands because the lungs are elastic.
When you lose the negative sucking pressure in the pleural space, the lung collapses. The lung is incredibly elastic. If nothing is holding it expanded, it will just collapse like a rubber band. This can happen if a bullet or knife penetrates the chest cavity, poking a hole into the pleural space and breaking the seal. When a chest tube is inserted, it is usually hooked up to a suction. The suction replaces that negative pressure and allows the lung to expand again until that hold is healed over and sealed once again.
Pneumothoraces can definitely be life threatening and need to be diagnosed in a timely fashion. They are always on your list of possible diagnoses when a patient presents with shortness of breath. But they are not nearly as common as seen on TV. Furthermore, when they do present, it is not always in such an acute fashion.
Wednesday, June 27, 2007
Monday, June 25, 2007
Fat passes
When I was a third year medical student, I did my surgery rotation at a community hospital based in a wealthy neighborhood. Nowadays, many hospitals are struggling to stay afloat financially, so many of them rely on certain money making procedures. Plastic surgery, orthopedics, and gastric bypasses were the bread and butter for the hospital that I rotated through, so I became very well acquainted these procedures, especially gastric bypass.
Gastric bypasses are quite complicated. They take a good couple of hours to complete and usually require a fairly large incision. For a medical student, the larger the incision, the better because it means that you'll be able to see more. If you've had your appendix removed recently, you'll know that the incision they use is hardly 2 inches long. The surgeon basically has to use their finger to feel into that incision and dig out the appendix. The result is a small scar, but for the medical student, there isn't a whole lot to see, and this can be kind of boring.
Gastric bypasses usually involve stapling part of the stomach so that you feel fuller after eating just a small meal. Then the end of the stomach is cut off and rejoined at a point farther down the intestinal tract. This way, once food leaves the stomach, it bypasses a large portion of the intestine resulting in less absorption of calories.
The first few times I saw a gastric bypass, it was pretty fascinating. Cutting off the stomach and then re-attaching it at a different point (anastamosing) seemed like basic plumbing, but was surprisingly complicated. It involves careful stitching with delicate hands. And the fact that there is such a large incision means that you can see other organs: the liver, gallbladder, stomach, small intestine, large intestine, and if you're lucky a urinary bladder.
There was one unusual attending at this hospital that everybody loved working with. Surgeons are typically a different breed of doctors. They are mean, demanding, arrogant, and have a certain air about them. But this attending was different. He was the nicest guy and was very approachable. He wanted desperately to get people interested in surgery so he would let medical students do a lot during surgery.
As a medical student doing a surgery rotation, the most involved they get, procedurally, is retracting, or holding "stuff" back. Surgery is all about exposure. You can't cut or stitch if you can't see it properly. So exposure is incredibly important. But it is tiring and boring. It basically involves holding a metal instrument in one position for 10 minutes until the surgeon repositions you to hold for another 10 minutes. Repeat x10 and you're done. When you start holding back 50lb pieces of flab, it gets tiring.
But this one surgeon would get you more involved than just retracting. He would let you make the first cut, do part of the anastamosis, tie off bleeders, and even close the wound. And all the while, he was walking you through it very carefully, almost like a father would, and teaching the finer points of being a surgeon. He once let me do an appendectomy all by myself. These are the moments every medical student dreams of--actually making a difference.
I remember one gastric bypass that I did with him. The abdomen had been opened up and I was staring down at the intestines, ready to proceed. The surgeon took my hand and guided it into the abdomen. He said, "here, reach in and feel this woman's bladder." So I reached down cautiously and felt around the wound. "Farther," and he proceeded to shove my entire arm into the woman's abdominal cavity. I was in up past my elbow feeling for the woman's bladder. I wasn't quite sure what I was feeling for, but all of a sudden, I realized how strange it was to have my arm sticking into the belly of a 400lb woman. It was warm in there (I don't know why it wouldn't be)and you can kind of feel the intestines beneath you squirming around. I was holding my arm into darkness. For all I knew, there was something lurking in there about to bite me. I had no idea what a bladder felt like. Everything in there is soft and mushy. The surgeon pushed my arm in even further and all of a sudden I knew I had reached the bladder. It was slightly firmer and had a round contour. Exactly where I remembered it would be from my anatomy class. "Alright now get your arm outta there, you turkey!" (he called everyone a turkey).
That was cool.
Eventually any surgery becomes boring when you watch too many of them. And we typically did 2-3 gastric bypasses a day. We got really sick of them and eventually it became a chore. We affectionately renamed the procedure to a "fat pass". On rounds our presentations went something like, "this is a 45 year old woman, post-op day 2 from a gastric fat pass".
Very rude and insensitive, but hey, this was our surgery rotation.
Gastric bypasses are quite complicated. They take a good couple of hours to complete and usually require a fairly large incision. For a medical student, the larger the incision, the better because it means that you'll be able to see more. If you've had your appendix removed recently, you'll know that the incision they use is hardly 2 inches long. The surgeon basically has to use their finger to feel into that incision and dig out the appendix. The result is a small scar, but for the medical student, there isn't a whole lot to see, and this can be kind of boring.
Gastric bypasses usually involve stapling part of the stomach so that you feel fuller after eating just a small meal. Then the end of the stomach is cut off and rejoined at a point farther down the intestinal tract. This way, once food leaves the stomach, it bypasses a large portion of the intestine resulting in less absorption of calories.
The first few times I saw a gastric bypass, it was pretty fascinating. Cutting off the stomach and then re-attaching it at a different point (anastamosing) seemed like basic plumbing, but was surprisingly complicated. It involves careful stitching with delicate hands. And the fact that there is such a large incision means that you can see other organs: the liver, gallbladder, stomach, small intestine, large intestine, and if you're lucky a urinary bladder.
There was one unusual attending at this hospital that everybody loved working with. Surgeons are typically a different breed of doctors. They are mean, demanding, arrogant, and have a certain air about them. But this attending was different. He was the nicest guy and was very approachable. He wanted desperately to get people interested in surgery so he would let medical students do a lot during surgery.
As a medical student doing a surgery rotation, the most involved they get, procedurally, is retracting, or holding "stuff" back. Surgery is all about exposure. You can't cut or stitch if you can't see it properly. So exposure is incredibly important. But it is tiring and boring. It basically involves holding a metal instrument in one position for 10 minutes until the surgeon repositions you to hold for another 10 minutes. Repeat x10 and you're done. When you start holding back 50lb pieces of flab, it gets tiring.
But this one surgeon would get you more involved than just retracting. He would let you make the first cut, do part of the anastamosis, tie off bleeders, and even close the wound. And all the while, he was walking you through it very carefully, almost like a father would, and teaching the finer points of being a surgeon. He once let me do an appendectomy all by myself. These are the moments every medical student dreams of--actually making a difference.
I remember one gastric bypass that I did with him. The abdomen had been opened up and I was staring down at the intestines, ready to proceed. The surgeon took my hand and guided it into the abdomen. He said, "here, reach in and feel this woman's bladder." So I reached down cautiously and felt around the wound. "Farther," and he proceeded to shove my entire arm into the woman's abdominal cavity. I was in up past my elbow feeling for the woman's bladder. I wasn't quite sure what I was feeling for, but all of a sudden, I realized how strange it was to have my arm sticking into the belly of a 400lb woman. It was warm in there (I don't know why it wouldn't be)and you can kind of feel the intestines beneath you squirming around. I was holding my arm into darkness. For all I knew, there was something lurking in there about to bite me. I had no idea what a bladder felt like. Everything in there is soft and mushy. The surgeon pushed my arm in even further and all of a sudden I knew I had reached the bladder. It was slightly firmer and had a round contour. Exactly where I remembered it would be from my anatomy class. "Alright now get your arm outta there, you turkey!" (he called everyone a turkey).
That was cool.
Eventually any surgery becomes boring when you watch too many of them. And we typically did 2-3 gastric bypasses a day. We got really sick of them and eventually it became a chore. We affectionately renamed the procedure to a "fat pass". On rounds our presentations went something like, "this is a 45 year old woman, post-op day 2 from a gastric fat pass".
Very rude and insensitive, but hey, this was our surgery rotation.
Friday, June 15, 2007
Anatomy of a Prescription
I still remember the first time I wrote a medication order. Tylenol 650mg PO/PR q6h PRN fever. I ran all over the hospital, looking for my supervising resident to ask if I had done it correctly. Indeed I had...my first success.
Everybody has had the experience of going to the doctor's and coming home with a prescription written illegibly with 10 sanscrit-like letters, which after filling at the pharmacy, somehow becomes 10 words on the actual label. Ever wondered what those abbreviations mean?
The first word of a prescription is always the name of the drug. Tylenol. Acetaminophen is the generic name of tylenol (Tylenol is the brand name). Brand name drugs are manufactured by the company that did the research and "invented" the drug. Since they invented the drug, they are free to patent it and make money off of their research. But after 15 or so years, the patent expires and other companies are free to make the drug. They usually do so at a much cheaper price since this opens the door to the free market and competition.
Usually when a script is written, the generic form will be given, even if the prescription is written for the brand name unless "no substitutions allowed" is specifically indicated.
For most purposes, the brand name and generic versions are biologically identical. (There may actually be chemical differences, but this usually does not effect how the drug works).
After the name of the drug comes the dosage. Most drugs are dosed in milligrams. Obviously the dosage prescibed to you depends on many things: how potent the drug is, how much medicine you actually need, etc.
The next line includes how the medication should be given, or the route of administration. This is where the ancient abbreviations come in.
P.O. - by mouth
I.V. - by intravenous
I.M. - intramuscularly (a shot in the butt or arm)
S.C. - subcutaneously (a shot just under the skin)
S.L. - sublingual (under the tongue)
P.R. - per rectum (rectal suppository)
Obviously most outpatient prescriptions are PO since this is the easiest, but there are advantages to the other routes of administration. IV medications are usually more potent and start working much faster than pills. IM medications are not quite as fast to work as IV meds, but there are times when you might not want to start an IV on the patient. Rectal suppositories are good for when patients aren't allowed to take things by mouth (NPO, or Nothing PO).
After the route of administration comes the frequency, or how often the medication should be taken. Here are some more abbreviations:
QD - daily
BID - twice daily
TID - three times daily
QID - four times daily
QOD - every other day
Alternatively, the letter "q" can be used to mean "every". So "q6hours" means "every 6 hours). This convention has affectionately been applied to describe call schedules. So if you ever hear an intern say, "the call schedule is q3", it means that they are on call every third night.
After the frequency, physicians often will write "PRN". This means "as needed for ___". For example PRN pain means as needed for pain. So if there is no pain, obviously no medication is needed.
The last line of the prescription is usually just the amount of medication to dispense. It is frequently written as a number sign (#) followed by a number, signifying the number of pills to dispense. And then of course the bottom of the prescription usually has an area where the number of refills can be written.
So Tylenol 650mg PO/PR q6h PRN fever is just fancy way of prescribing tylenol 650mg by mouth or rectal suppository every six hours as needed for fever.
There you go, now you know what your doctor is prescribing for you. Now if only you could read the handwriting...
Everybody has had the experience of going to the doctor's and coming home with a prescription written illegibly with 10 sanscrit-like letters, which after filling at the pharmacy, somehow becomes 10 words on the actual label. Ever wondered what those abbreviations mean?
The first word of a prescription is always the name of the drug. Tylenol. Acetaminophen is the generic name of tylenol (Tylenol is the brand name). Brand name drugs are manufactured by the company that did the research and "invented" the drug. Since they invented the drug, they are free to patent it and make money off of their research. But after 15 or so years, the patent expires and other companies are free to make the drug. They usually do so at a much cheaper price since this opens the door to the free market and competition.
Usually when a script is written, the generic form will be given, even if the prescription is written for the brand name unless "no substitutions allowed" is specifically indicated.
For most purposes, the brand name and generic versions are biologically identical. (There may actually be chemical differences, but this usually does not effect how the drug works).
After the name of the drug comes the dosage. Most drugs are dosed in milligrams. Obviously the dosage prescibed to you depends on many things: how potent the drug is, how much medicine you actually need, etc.
The next line includes how the medication should be given, or the route of administration. This is where the ancient abbreviations come in.
P.O. - by mouth
I.V. - by intravenous
I.M. - intramuscularly (a shot in the butt or arm)
S.C. - subcutaneously (a shot just under the skin)
S.L. - sublingual (under the tongue)
P.R. - per rectum (rectal suppository)
Obviously most outpatient prescriptions are PO since this is the easiest, but there are advantages to the other routes of administration. IV medications are usually more potent and start working much faster than pills. IM medications are not quite as fast to work as IV meds, but there are times when you might not want to start an IV on the patient. Rectal suppositories are good for when patients aren't allowed to take things by mouth (NPO, or Nothing PO).
After the route of administration comes the frequency, or how often the medication should be taken. Here are some more abbreviations:
QD - daily
BID - twice daily
TID - three times daily
QID - four times daily
QOD - every other day
Alternatively, the letter "q" can be used to mean "every". So "q6hours" means "every 6 hours). This convention has affectionately been applied to describe call schedules. So if you ever hear an intern say, "the call schedule is q3", it means that they are on call every third night.
After the frequency, physicians often will write "PRN". This means "as needed for ___". For example PRN pain means as needed for pain. So if there is no pain, obviously no medication is needed.
The last line of the prescription is usually just the amount of medication to dispense. It is frequently written as a number sign (#) followed by a number, signifying the number of pills to dispense. And then of course the bottom of the prescription usually has an area where the number of refills can be written.
So Tylenol 650mg PO/PR q6h PRN fever is just fancy way of prescribing tylenol 650mg by mouth or rectal suppository every six hours as needed for fever.
There you go, now you know what your doctor is prescribing for you. Now if only you could read the handwriting...
Legal-ese
Before proceeding, I have to say that this blog is intended for education and entertainment. It is in no way a substitute for proper medical care and readers should have their own physician because each patient is different.
Basically what I'm trying to say is don't sue me because you read something in my blog and then go and do something stupid.
Basically what I'm trying to say is don't sue me because you read something in my blog and then go and do something stupid.
My First Post
I suppose I should start by introducing myself and explaining what I'm trying to do with this blog. My name is Byron and I graduated from medical school 12 months ago. For the past year, I have been slaving away as a first year resident (aka intern) at a local community hospital. I have 4 more years of training until I achieve my chosen specialty, radiology.
I loved medical school. Most doctors hate it because of the shear amount of memorization and long hours. It is truly mind boggling when I think back, but despite all that, I loved it. I loved the science behind it. I loved finally learning why our body behaves the way it does, why medicines do what they do, and why doctors are the way that they are. I didn't mind the work because I was so engaged.
And let's face it. America loves medicine too. Just turn on the TV and it's ER, House, or Doctor 90210. Open up Newsweek and every other story has to do with a drug company, health care in America, or how to ward off Alzheimer's. There is an obsession with medicine in popular media.
My girlfriend during medical school (now my fiancee) had to put up with a lot--it's not easy being a doctor's wife. But she got to hear all my little stories. She heard about the time I had my arm inside a 400 pound woman's abdomen (past my elbow!) and the time one of my classmates got pooped on by a woman in labor. She also got to hear my explanations of why knuckles crack, why she should stop biting her fingernails, why most cardiologists think Lipitor should be in the drinking water, and why nurses, not doctors, are the ones who run hospitals.
I want to share my experiences and knowledge with others. Each post, I thought I'd tell a story about an interesting patient, comment about how healthcare is delivered, or give a brief lesson in medicine. That way, you can have a taste of what it is like to become a doctor. Pretend you're a medical student.
I loved medical school. Most doctors hate it because of the shear amount of memorization and long hours. It is truly mind boggling when I think back, but despite all that, I loved it. I loved the science behind it. I loved finally learning why our body behaves the way it does, why medicines do what they do, and why doctors are the way that they are. I didn't mind the work because I was so engaged.
And let's face it. America loves medicine too. Just turn on the TV and it's ER, House, or Doctor 90210. Open up Newsweek and every other story has to do with a drug company, health care in America, or how to ward off Alzheimer's. There is an obsession with medicine in popular media.
My girlfriend during medical school (now my fiancee) had to put up with a lot--it's not easy being a doctor's wife. But she got to hear all my little stories. She heard about the time I had my arm inside a 400 pound woman's abdomen (past my elbow!) and the time one of my classmates got pooped on by a woman in labor. She also got to hear my explanations of why knuckles crack, why she should stop biting her fingernails, why most cardiologists think Lipitor should be in the drinking water, and why nurses, not doctors, are the ones who run hospitals.
I want to share my experiences and knowledge with others. Each post, I thought I'd tell a story about an interesting patient, comment about how healthcare is delivered, or give a brief lesson in medicine. That way, you can have a taste of what it is like to become a doctor. Pretend you're a medical student.
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