Not much action the last couple days. I’m enjoying the chance to explore the hospital’s library, and do enough studying during the day that I don’t have stay up with the books at night. On the other hand, I’ve been dutifully trying to read the chapters on anatomy, so I’m also getting a fair amount of sleeping done during the day – semi-unintentionally. I figure ought to read about liver anatomy, with all those confusing segments and branches, because it’ll be years before I ever get to see any, and even then there won’t be much. Somehow asking the hepatobiliary surgeon to explain the subject doesn’t seem like a promising approach. Several chapters later on, though, is a long and fascinating section on the treatment of hepatic cysts caused by various parasites. There are many cool pictures, and it seems fascinating to have so much time devoted to a disease which is almost never encountered in the US.

Yesterday I saw my first patient with true peritoneal signs. I had almost started to doubt their existence, since every time I suggested that I had found some, the seniors scoffingly contradicted me. Even uninsured people and illegal immigrants tend to come to the ER before things get that bad, so all the appendicitis cases I’ve seen have been early enough that you couldn’t really call it rebound tenderness or rigidity. I’ve gotten so used to assuring myself and other people that there are no signs of peritonitis that I almost missed this one. (Yes, bad; that’s what surgeons are for, to recognize peritonitis and take care of it.) She was lying in bed perfectly still, gazing up into the corner, and not really moving at all. She didn’t want me moving the sheets over her stomach, or even touching the skin – let alone anything deeper. Silly me, I wasn’t quite sure how bad it was, so I bumped the bed too. This is supposed to be a little more subtle; if the pain is not that bad, or if the patient is malingering at all, it shouldn’t cause too much of a commotion. She yelled. I went to look for the chief, who organized the patient into the OR before the attending could get there.

(For the non-medical readers: peritoneal signs, like an abdominal wall that’s rigid to the touch, or rebound pain, which hurts more when you let go than when you press, are signs of serious intra-abdominal pathology. They indicate that the disease process, whatever it might be, has progressed to the point that the entire peritoneum is inflamed and tender, rather than just the limited area around the original problem. If you say the patient has peritoneal signs, it means you have a true emergency and need to plan for immediate surgery. Which is why non-surgeons may say this to get the surgeon’s attention, and why surgeons rarely say it.)

I also had time to look at some newspapers today. I think I should refrain from the practice. I see Romney has dropped out, which apparently leaves the Republican nomination in McCain’s hands. I’m obliged to respect him as an individual because he was a prisoner of war in Vietnam, and I am in awe of those men; but his policies leave a great deal to be desired. And on the other side, we have Obama and Hillary. I don’t know whether to hope Hillary wins the nomination, because it would make for a crazy race, and hopefully she would lose (I expect in the end too many people would be frightened of really having her – and Bill – as president), or to hope Obama wins, because then there’d be no chance of Hillary winning. Yes, definitely time to drop back underground until November.

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