"Turn your head and cough. please!" Day 11

This morning I felt like I was a very unfit 90 year old lady. It took a few minutes of walking around before I could actually move my back.

We had two procedures today.

Circumcision: Sadly it wasn't the right Dr.H doing the operation otherwise I'd probably get to sew again. I got to assist though and felt pretty confident in that role ;)

Cystectomy: Bladder removal. Normally, if the patient doesn't have a lot of other problems or a complicated anatomy, this procedure takes only a few hours. This patient had both and it took 6 hours!!!

The bladder was encased in fibrous tissue and the intestines were stuck together. The process of removing the bladder took the most time because of all of this. Since the patient had a few other medical issues a general surgeon came and operated later on.

I was second assistant because two attendings were operating. There wasn't much for me to do other than occasionally hold a few hooks. I woke up pretty tired this morning and really fought to focus and pay attention during the operation. To be honest, I was bored just standing there and hardly being able to see anything. If this had been my first operation ever, every little move the people make would be interesting but since this wasn't, it is kind of as if I was just standing in one place for hours on end. You'd be bored too.



If I was operating myself I'm sure I'd feel differently and be so focused on what I was doing that I wouldn't have time to feel my back pain. Luckily after about three hours, the general surgeon showed up to operate with the other two. Since there wasn't any more room at the table I was told to go have a coffee break.

I did for about 20 minutes and then returned to watch some more. Once the general surgeon finally left I got washed up and joined the surgeons again to hold a few more hooks.

What made it all fun though was the team. It's a great mix of people that joke with each other. Makes operating a lot more enjoyable than grumpy, serious and quiet people.

After 6 hours we had the patient cleaned up and out of there. And I was right behind him.

Got this little message from a friend and had to share!

"When I was young, I decided to go to medical school. At the entrance exam, we were asked to rearrange the alphabets:

P N E I S

and form the name of an important human body part which is most useful when erect.

Those who answered SPINE are doctors today, while the rest are on Facebook."

Now I beg to differ if you end up in Urology ;)

Baci, V
 

"Turn your head and cough, please!" Day 10

My poor back. I think once I am in any position to say something and make decisions, especially in my OR, it will be that things are done more back friendly.

There were only two procedures today but the first was 4 hours long and spectacular (except for the at times extreme back pain from standing).

Today I witnessed the first ever DaVinci operation in the Medical School Hospital of Göttingen. My chief was operating. He had apparently gotten a lot of hours of training in a different hospital and conferences because he performed the operation without any major problems. So what exactly is DaVinci? It's this beast:

How does it work?

-Five people are essential for the operation to work.

• Operating surgeon
• assisting  surgeon
• OR nurse
• OR runner (get supplies for the OR nurse who is sterile and can't touch unsterile things)
• and the anethesiologist

-The patient is prepped as though he was having a laproscopic operation done. So instead of cutting the patient open, five holes are made where various instruments are inserted and the inside is made visible with a camera.

-The difference in the DaVinci procedure is that the operating surgeon isn't standing by the patient with his two instruments inserted in two of the holes but rather the DaVinci device is attached to two of the holes while the surgeon sits in a sort of console and operates the DaVinci machine from there.

-So the assistant is still standing at the table and inserting various instruments to essentially help the robot arms (inserting needles, removing tissue, sucking away the blood).

Why my back killed.

Most of the operation, this chair was right next to me:

My back was killing me from the standing so I tried all different kinds of subtle stretches to ease the pain and even thought about inventing OR-Yoga to help others. I was happy to see one of the assistant doctors (not operating but observing like me) was also stretching his back or had his thigh on the above pictured chair but he also never sat down.

At some point the older nurse (the oldest person in the room) momentarily sat down on the chair. I feel that was legit.

But why didn't Dr.M or I ever sit down in those 4 hours? I thinks its a hierarchy thing. Every one in that room knows that standing around for 4 hours in one spot will hurt your back. The chief was the only one (except for the anesthesiologist) sitting during the procedure. The assistant surgeon (who happened to be the attending) had to stand.

So if he had to stand the 4 hours and not move, what gave us the right as merely observers to be more comfortable than him? It would have looked really bad had I, as the little medical student, made myself comfortable on the chair while everyone else got to stand in pain. So it's a combination of hierarchy and solidarity I guess. Or at least it is in my head. So there I stood thinking up the next big fitness wave called OR-Yoga while watching the operation.

So what was done?
The patient's prostate was removed. It was crazy how the surgeon at the console was controlling the machine to actually sew things and cut and navigate through the set holes and the filled-with-gas stomach of the patient. Check out the doctor at work:

Luckily for me a representative of the DaVinici system was there to help. This was only practical for me because reps are known to bring food along for the OR-team and that is exactly what he had done. I was starving, cold and aching by the end of the operation so the three brötchen (German bread with something on it) and candy where a life saver (and I didn't have to buy food...I'm on a low student budget after all).

The other operation was an open kidney biopsy. Dr.H, Dr.M and I where done with that in less than an hour. Go team!

I debated going to the lab after all the work was done but then decided to enjoy the good weather a bit and hit up the basketball court with a good friend. Sometimes you just gotta live a bit...

Baci, V

"Turn your head and cough, please!" Day 9- off with his head! (Wellsorta....at least his hat)

Snip, snip, snip!

It's finally my operation week!

Get 'er done!

I watched four procedures.

-A cystoscopy (looking at the bladder with a camera) was done before a 

-colonoscopy (looking at the large intestine with a camera) on the same patient

-a nephrectomie, due to a tumor the whole kidney had to be removed. I got to hold hooks but not much more because another assistant was there as well.

-a circumcision on a grown man.....and I got to help! The doctor did the snipin and I did the stitchin! I love that Dr.H let's me sew up in his surgeries. 

All of these things with set up and take down lasted from 8AM to 1:30PM. 

After that I headed into the lab and worked with my attending professor for a few hours on the fluorescence microscope.

Tomorrow is supposed to be a packed schedule including the DaVinci system! So basically the doctor plays a video game on a console while a robot operates. I'm excited to see it happen. Full report tomorrow!

Baci, V

"Turn your head and cough, please!" Day 8 - just keep swimming

Well it was another successful day of sitting around and waiting for something to happen. If anything, I did more office work and management than anything else the first half of the day.

Dr.H working the outpatient department today seemed to always be a step away from a heart attack. I didn't really want to bother him and ask him to show me things in his state. So I sat around and looked for work to do. 

What I do to waste time...

Dr.K gave me a huge pile of patient files that he had received during the morning meeting that needed the diagnoses coded with the DRG system. That was actually kind of fun because I had to look through the files and see what the patient had and then find the code and coolest of all, I had to sign the papers. It gave me a little feeling of power that I had made this decision and it was going to be used. Silly, I know.

At some point Dr.H wanted Dr.W to come down and help out. He showed up temporarily and decided there was nothing for him to do there. The nurses, Dr.H and I preceded the next two hours looking for Dr.W. we paged him, we called all the wards, we asked everyone we saw, I even texted the elective working with him for the day. Nothing. Eventually we found out he was in the OR (odd for him since he doesn't like it there) and thus could not be reached.

I almost gave up on the day and wanted to go home but then the only female doctor in the department at the time came to help out and started taking me to see the patients. She had me be very hands on. I did a testicle ultrasound on two different patients. I drew blood. I did the routine ultrasounds. 

I was excited that she was so active but kept fighting with the thought of wanting to go home and get some sleep before my night shift. We proceeded to go back to the ward and do afternoon rounds before heading back to the urology management department for the afternoon meeting. The other electives were long gone of course. We looked for the attending and found him with the other attending and chief. They were all sitting around and drinking coffee. Do they not have lives? Anyways, at some point the chief asked if they didn't want to let the young colleague, aka me, go home. I told him he didn't have to tell me that twice. See ya!

On the way to my locker I saw that I had a call from my night shift office. I called back to find out that they were giving me the night off because there weren't enough patients that needed us and since I had enough overtime I got the night off.

I quickly went to the grocery store and bought a pizza to eat since I hadn't had a meal since 6:30 that morning and it was already 4PM. It was kind of a little insight into how my residency will someday be. living off of whatever is quick and easy becaue I haven't eaten all day. I also quickly organized a ride to Berlin for my god child's birthday. So now I am sitting on the couch with my cousin and chilling. A nice alternative to 8 more hours hospital. 

I'd like to give a shout out to my big sis Fran for starting med school in Erie Pennsylvania today! I'm happy you get to persue your dream. It's a great one but its also one that at times will break you down, push you to your limits and make you question your decision. Just keep swimming (Dory vocals here). The best of luck! (Everyone can check out her blog www.franish.blogspot.com)

Alright everyone, have a great weekend! See you Monday!

Baci, V

"Turn your head and cough, please!" Day 7

Well, it was another day of looking for things to look at and do. Nothing as shocking as penis piercings today. But I did find a Playboy booklet with the best 500 playboy jokes. The other elective was reading it but I will grab it tomorrow and see what I can find ;)

The morning meeting was brief and after the doctors' "lung therapy" I was upstairs in outpatient care again.

Destroy it!
A pretty cool thing I did see today was a PCNL aka percutaneous nephrolithotomy. Basically the patient has a kidney stone that is too big or to risky to pull out through the ureter. If you YouTube pcnl you'll find a video with some dramatic music showing the process. (Someone actually sat down and put that music to that video footage. Cracks me up.) Once you have access to the kidney, the stone gets crushed with ultrasound waves. I imagine it being more fun to do than to watch. Someday.

"Oh I'm sorry for wanting to get something done around here......NOT!"
Other than that I helped out with the outpatient appointments. I even got a bit of an attitude from one of the nurses because I decided on my own to go in and take the patient's history for Dr.W. I came out of the room looking for him and the nurse just gave me a bitchy look and told me I was the cause of confusion because they thought another doctor was working with me since Dr.W. didn't know why I was in the room. I instantly felt bad because honestly, I am rightfully a little afraid of nurses with bad attitudes. Instantly I apologized to Dr.W. for the confusion and explained that I was merely doing him a favor in taking the history. He didn't really seem to care that I had done so and had taken a smoking break. So sassy miss nurse decided to spread a bad energy just for the heck of it.

Writing doctory
I ended up being asked to write the doctor's letter for the patient again. I told Dr.W off the bat that he better give me more than 10 minutes to get it written and proof read. I know it sounds silly, especially when you hear me speak German but German grammar is extremely difficult. Even the other elective that looked at my letter had some issues. In the end Dr.W was actually quite pleased with the contents of the letter but changed a lot to sound more "doctory".

After all the regular patients were seen I headed into the lab to get some work done.

Tomorrow is a pretty busy OR day so I might hop in here and there depending on what is happening in outpatient. :)

Baci, V

"Turn your head and cough, please!" Day 6-- Sorry for the break

Due to a funeral, I was not in the hospital on Monday or Tuesday.

There is a world of a difference if you have to be in the hospital by 7AM or at the morning meeting at 7:45AM. It sometimes feels like there is a collosal difference, while looking at the alarm clock, between 6:48 (the time I woke up) and 6:50 (the time the alarm was supposed to go off) but I'm sure everyone feels that way.

It is my week to be in outpatient care. Since I'm only present 3 of the 5 days I didn't want to miss out on all the operations. I also don't mind being in outpatient care. You see the most patients and most variety. It's also the place where I get to do the most. Today I even saw my own patients!

The day was not super busy though. I had prepared myself for such an occasion with research papers to read. I read one. It was way more interesting chatting with the nurses :) So what all did lil 'ole me with my innocent eyes get to do and see? Well....

Two double pig-tail stent replacements
Another reason why I am sort of destined to be a urologist. We have pigtail stents! Anyone who knows me can tell you that I LOVE pigs. I even have a pot belly pig Pigcasso at home being taken care of so lovingly by my mom (thanks mom!).

But in the medical field, these stents are used to help urine get from the kidneys to the bladder for various reasons e.g. kidney stones, stenosis, other obstructions.

UTIs are a urologist's daily bread
Next to prostate hyperplasia (large prostate), urinary tract infections really are a very, very, very common thing in urology. Especially with young women. A differentiation can be made between lower (bladder) and upper (kidney) urinary tract infections. I really want to start using the acrynom FLUTI for female lower urinary tract infections. How fun! "I went to the doctor today. I have a FLUTI." Makes it sound so much less painful! I'll see if I can make it a thing.

Usually a FLUTI is caused by E.Coli. Females (unless there are serious complications or are preggers) shouldn't get antibiotics right away because they tend to go away by themselves. Most import is that the patient drinks a LOT of water to wash out the bothersome bacteria. If men have a UTI it is always considered "complicated" and they are given antibiotics because of all their anatomical structures that could easily be harmed.

Two of the patients that I got to take care of had UTIs. Dr.K let me go in by myself, take the history, do the ultrasounds and then report back to him with my suggestion of therapy. I filled out all the paper work and just had him sign off on everything. It was a nice feeling knowing that I could at least do that much.

One of the patients has been having UTIs the past 20 years on and off again. She told me that each doctor just writes a prescription for antibiotics and then says if it doesn't get better, further diagnostic measures will have to be performed. When she then goes back to the doctor they just give her another antibiotic. I talked the situation through with Dr.W to see what possibilities where available so they could be started on the patient and organized an appointment for her with the attending to finally discuss the options she had.

Well I've never seen a piercing there personally....until now
The things people do to their bodies. It's fascinating. I'm one to talk on a small level. It seems every time I fly home, I have a need to get a new piercing. I put a piercing ban on myself though because it is getting exceedingly difficult to coordinate all my piercings. Especially since all of mine are visible in daily life.

The patient I saw today though probably doesn't have the same problem. He had two piercings...down there. And when I walked into the room I perceived him as quite the business man and was not expecting that. I guess you just never know what people are carrying around in their pants.


As much as I don't like waking up early in the morning. I must say I don't mind being there once I am. I feel really comfortable in the department and with the patients. The team really is great fun. Dr.K and I had a lot of time to chat. Dr.W sent the other electives home at 11:30 because nothing was going on. He didn't tell me that though until 2pm. I didn't care though. I was having my fun and was such a nerd and stayed for the afternoon meeting. Me and 4 male doctors. Now we are talking! My kind of crowd! :D

Baci, V

"Turn your head and cough, please!" Day 5

Coming to you live from my night shift station. Hopefully my two patients will just sleep through the night and I can get some work done. You just never know how the 8 1/2 hours will go. People do crazy things in the middle of the night sometimes. But let me tell you about my day first.

My posse

Rounds were good and we were just a wee bit late for the morning meeting. Probably the most interesting fact from the meeting was that we had an operation happening today because a penis pump dislocated and was actually protruding out of the skin! Obviously I wanted to see that. But first it was off to the wards to get stuff done.

Job description: Vampire
If you aren't lucky and end up in an elective were the doctors don't care and basically just use you, you will be drawing blood all day. Not that fun but great practice. I am in the fortunate position that I have a really friendly team. Nonetheless we are responsible for the blood drawing. I'm quite happy about it because the practice can't hurt and in my other electives I wasn't allowed to even touch the patient (thank you American hospitals). I like drawing blood. Getting a venous catheter in is another story. I really need my practice in that. Anyways, I was happy when I went to draw blood from a patient and he told me I was going to have a hard time since his veins were so bad and it  worked on the first try. The patient seemed more excited than I was telling me no one had been able to draw blood on the first try in 10 years! Booyah!  

Viktoria 1 : Veins 0

Difficulties while drawing blood: If you have a patient that has veins like me or a young male where you could throw a needle from 10 feet away and still hit, you are lucky and drawing blood is easy peasy. Situations in which it gets difficult,

• Old granny with basically non existing veins (if this is the case, drawing blood from the femoral vein might have to happen. Big ole needle through the groin area. It looks like it should hurt but some patients prefer it so it can't be all too bad. I've personally never done it.)
• Darker skin color: People usually like seeing where they are sticking the needle which is difficult with pigmented skin
• Straight up not visible: This is where I give everyone the advice to feel the veins. The ones you can't see through the skin are often the best ones for drawing blood. You just have to trust your visual thinking. But it works, I promise :)

So, when can I have sex again?
Dr. W and I finished up a few patient letters and set up appointments before heading to outpatient care since they were quite busy. Apparently everyone wants to see the urologist before the weekend. A summary of the cases:

look! My outfit goes well with the outpatient floors

• A man wanting a circumcision because of foreskin tightness. (Dr.W kind of dissed the American's saying if the patient had been born there he wouldn't have this problem since most boys are circumcised without being asked if that's what they want. Can't say I've heard a single guy complain about missing his foreskin but hey, to each his own. The patient responded by saying he wouldn't have minded being born there. I was afraid it was going to turn into a ethical debate.)
• A man came in and we had no idea why he was there or who had sent him. He wasn't able to communicate with us either. Perfect. We took a look around and I did an ultrasound of his bladder, prostate and kidneys. We couldn't find anything suspicious accept that his penis was a bit smaller than average which would point towards a low testosterone level. We ended up finding out that he was supposed to be transported to his urologist in town for a shot against prostate cancer. This would explain our findings. Prostate cancer patients are given anti-androgens which lower the testosterone level.
• A woman with bloody urine (I had to go to the OR in the middle of taking care of this patient so I don't actually know why her urine was bloody or what they ended up doing.)
• An ileum conduitoscopy was performed. An ileum conduit is another form of replacing a bladder in contrast to the neobladder I wrote about yesterday. A piece of small intestine is attached to the outer stomach and is open to the environment. A bag it placed over the opening to collect the urine. The ureters are attached to the ileum conduit on the inside of the body. It looked a bit bizarre from the outside. Anyways, the patient also had bloody urine flowing so the attending took an endoscope to look around.
• A check up appointment with a young male after circumcision. His main question was when he could start having sex again. His girlfriend was getting ansy after 2.5 months. Oh teenagers...

What is the patient's feeding tube doing?
I headed into the OR to see the second half of the implant removal. I arrived in the OR at the point where they had already removed half of the pump and where working on the other half. It's rather interesting to see how a little pump is implanted into the scrotum and the inflatable tube in the shaft. I just imagine it being too funny to pump up an erection by squeezing the scrotum. But hey....its the result that counts, right? How you get there isn't that important ;) After they had removed the whole pump system (since it was badly infected and the patient wasn't going to need its function anymore anyways we didn't implant a new one), he was given a suprapubic catheter, (The bladder is filled with fluid and then a big needle is poked through the lower stomach to the bladder and urine flows over a tube into a bag.) and sewn up.

All green everywhere

Dr.H is too funny. I was standing by the patient's head with two nurse students watching the operation. Dr.H was holding on to the tube that ran from the scrotum to the penis. As he pulled on it, trying to remove it, he asked us if the patient's feeding tube was moving in further. We three quickly checked to see what the feeding tube was doing not realizing that he was totally messing with us. Lol. It was funny to see how quickly we just obey without thinking about why. He got us.

Dr.H 1 : Students 0 

I really think I'll like working in Urology if those are the kind of guys I'm working with.


I told you it's bad! No really....it's bad!
Back on the ward I was supposed to write a patient release letter. I told Dr.W my German grammar was horrendous and that it would take me some time to get the wording down. He came back so fast though that I had just gotten my rough draft ready (very very rough). He said it couldn't be all too bad and read it. I really didn't want him to knowing exactly that would happen which did. He was completely amazed just how bad it was. He thought I was just kidding. He was quite amused (as are my relatives and friends by my grammar as well.) Of course I don't like not being good at something but honestly people, my German grammar lessons are limited to 4th and 6th grade. I let the people laugh and have their fun and tell them they should speak English or write me a letter and then we will see who's laughing. Being bilingual is a gift but also makes life difficult sometimes because I mix up things from both languages without noticing. A lot of the time my friends will notice and laugh about it secretly or tell me months later after letting me go through life thinking I was saying it right or, if you are like my aunt, will have a good hard laugh at what I said and then tell me and proceed to tell the rest of the family. Dr.W was amazed because he said he doesn't notice anything when I speak to him. I said I just needed to read a lot of release letters to get a gist of the wording and then it wouldn't be a problem. But there is no way I am taking German grammar classes additionally to all the other stuff I have to do. It's just something I will have to work on to avoid another situation like today.

Where is everybody at?!
After that incident, I headed over to the lab to get my reactions from yesterday done. Except for the Professor, no one else seemed to be in the building. It was only 3:30pm. Guess they all left early for the weekend. After 1 1/2 hours I was done and headed home to nap before coming here.

So far my patients are sleeping. Lets hope it stays that way!

Baci, V