"Lasers"

"I have one simple request. And that is to have sharks with frickin' laser beams attached to their heads!" -Dr. Evil

You'd think that shining lasers in peoples' eyes isn't the best medical therapy. Surprisingly ophthalmologists use it for all sorts of treatments from diabetic retinopathy to retinal edema. And you wear the laser as head gear, how cool (or scary) is that! If you just kill off some of the retinal cells you can reduce oxygen demand and cut down on the amount of out of control arteriole growth in the back of the eye. Still, I'd rather avoid a laser in the eye if at all possible, that you very much.

Despite all my complaining, I have seen a bunch of eye pathology and other cool diseases that frequently have eye related problems...sarcoidosis, Wegner's granulomatosis, HLA-B27 ankylosing spondylitis, retinopathy of prematurity, lots of glaucoma, and a guy whose blood sugar was 1663. Talk about off the charts. Plus, unless I decide to become an ophtalmologist (not looking so good right now) this may be my one and only chance to learn about eye problems. It's true ophthalmologists get to do cool things...like transplanting a tooth into an eye to restore sight, I just never get to see them! However, I did observe two cataract surgeries last week which were pretty interesting and relatively non-invasive. With ultrasound and a 2.4 mm incision in the eye you can mix up the lens, extract it from the eyeball and put in a replacement. Way more high-tech than the surgery I saw in Guatemala where you had to make an almost 180 degree incision and then suture the eye back together. Ouch. Still it was a pretty impressive surgery to see in the middle of nowhere. I imagine cataract sugeries must feel pretty rewarding...with a half hour surgery and minimal complications you can reliably restore vision and really improve people's quality of life. You can't say that about many medical interventions.

Sadly, I'm trying to deal my own ophthalmology problem right now (and I don't mean preparing for that test). My wonderfully kitty, Katsumoto (above right), has been scratched in the eye my my devilish little kitty, Catastrophe, and has been all watery discharge and winky, blinky eye pain for the past two days. Hopefully it will improve on its own because my limited eye knowledge definitely does not extend to cats. Though Katsumoto loves to chase the laser pointer around, I don't think shining it in her eye is going to help in this situation.

Furthur

Is LSD Good for You? Oh the possibilities! I was just finishing up Tom Wolfe's trippy "The Electric Kool-Aid Acid Test" when I ran into this article on the renewed interest in the therapeutic potential of LSD. Fun stuff. Sure Lysergic Acid Diethylamide started out in the 1940s as a drug under investigation for specific psychiatric uses, but it quickly took on a psychedelic life of its own...good for you in the mind expanding, horizon broadening sense. Oh to be on the bus! If medical marijuana is controversial, I don't really see this going over well. But if it treats really bad cluster headaches better than anything else, how can you deny someone? On an ophthalmology related note... marijuana can lower intraocular pressure and therefore be used to help treat glaucoma. Plus, cocaine has long been used (though I don't think anymore) as a topical anesthetic for eye surgeries. Who says recreational drugs aren't useful?!?

Last night I saw a dance performance that absolutely blew my mind (and I wasn't on any drugs). It was amazing....like laugh out loud, speechless, crazy amazing. The work was called "Caught", by the Parsons Dance Company, and it featured a male dancer who essentially seemed to levitate due to extraordinary skill and the use of strobe lights. Strobe lights! Just like they used with the Grateful Dead at Ken Kesey's Acid Tests with his Merry Pranksters. Awesome! There was some other really great dancing, but nothing else quite as innovative (of course the dance was first choreographed in 1982, so I'm a little late to the party). Sadly the youtube video just doesn't do it justice at all. I mean, that's what it looks like, but you've gotta see it live. It reminded me of this equally jaw dropping exhibit I saw at the Guggenheim, "I Want to Believe" by Cai Guo-Qiang. The main work "Inopportune: Stage One" depicted a car bomb explosion created by nine cars somersaulting up the atrium with lights radiating out in every direction. Insane. Images suspended in time...just as if they were viewed under a strobe light...or maybe on an acid trip. Turn on, tune in, heal?

Abre los Ojos

It's been an interesting week in Ophthalmology...not exactly exciting, but, well...eye opening. I just finished seeing a guy with a corneal ulcer, that's gotten worse. Because he doesn't have the money to buy the antibiotics he needs. Because he can't work until his vision improves. Catch-22. Excellent. I'm working in an eye clinic that's essentially free to the patients, but we still can't cover all medication costs. Health care reform is in the air and can't get here soon enough...what form it takes, we'll just have to see. If nothing else, isn't there an economic imperative to keep healthy young people in working condition so they can contribute to society?

I digress...so far my ophthalmology experience has been pretty chill. All clinic, no surgery...so much for my surgical subspecialty rotation. I can't really complain because the hours are great and it was my top choice. Ophthalmology is the first thing I've done all of third year that I'm actually considering as a career. Which is why it's kind of a bummer that so far it's been a non-event. Essentially the other med student and I are work horses that do the patient work-up and vision exam, a job several rungs below the techs. I don't even do any actual eye exams which is the one thing I really wanted to learn since I thought it'd be useful in future practice no matter what.

The residents are nice and when you have the time to follow them you can learn something, but since most of them don't have teaching scopes, even that is limited. The indirect ophthalmoscopes are pretty awesome, I had the best view of the retina I've ever seen in my life. Unfortunately, unless I actually become an ophthalmologist (we'll see how the rest of this rotation goes) that's one gadget I'll probably never use. This weekend I desperately need to review some of my Español because at least a third of our patients speak nothing but Spanish. One woman didn't even know the alphabet...we had to use pictures. I can muddle through an exam ok, but I need to use the interpreter phone to be sure I'm not missing out on any critical history stuff. I've got a lot of studying to do in general between the ophthalmology test and our general surgery test. Gah. But enough complaining, I think I just have to be proactive about this experience...shadow residents as much as possible and do my own covert eye exams.

Every passing minute is a another chance to turn it all around.

Be Still My Heart

What's the difference between a cardiothoracic surgeon and God?
God doesn't think he's a cardiothoracic surgeon.

Love it.

The coolest part of anesthesia (besides intubating people...4 for 4, yay!) has been seeing all the different surgeries. Today I saw the beginnings of a lobe resection for lung cancer (a live view of a disgusting, black, cancerous lung would probably help people quit smoking) which involved preferentially ventilating the healthy lung and collapsing the one to be resected. Very cool. And yesterday I got to see a mitral valve replacement involving cardiopulmonary bypass. Modern medicine is pretty amazing. First we got to do a tracheoesophageal echo and get a really clear view of the heart in action, dysfunctional valves and all. Then I got to watch the surgeon cut open the guy's chest. It kind of freaked me out to see all the monitors flatline when the patient was switched over to the bypass machine, but obviously everything was very controlled. All I could think was...VAMPIRES!!! All that bright red blood going through the machine, being oxygenated and pumped back in...even Angel might not be able to control himself. Fortunately the patient made it through with flying colors.

I also saw a supraclavicular regional block for an arterio-venous fistula surgery (type I diabetes sucks). It was cool to see the brachial plexus on ultrasound but even though everything seemed to go smoothly, obviously the block wasn't effective enough because once the surgeon cut into the patient's arm he started moaning. Yikes! I mean not screaming bloodly murder like someone was cutting into his arm, but he was definitely feeling sharp pain. Awkwardly, the resident I was with didn't seem to want to admit that the block wasn't everything it should be. Every time the patient let out a moan he would lean in and ask "is the pain tolerable?". Okay, it's nice that he's inquiring...but pain is a relative thing and tolerable can mean many things to many people. I can certainly imagine that an old military veteran might not want to complain about being in a lot of pain. Man up. But there's no reason he should have to suffer when he's surrounded by pain killers. The surgeons kept injecting him with local anesthetics, but eventually the attending anesthesiologist came in and knocked him out. Not ideal, but it was probably best for the patient at that point.

Sadly I'm now done with my anesthesia rotation/amazing vacation. Next up: Ophtalmology!