Surgery Rotation: Inguinal Hernia Repair Pimping

So this is my first inguinal hernia repair surgery also called inguinal herniorrhaphy. I knew the layers of the abdomen (go check in a Netter if you dont know because they will ask you that for sure in OBGYN especially above and below a certain arcuate line which you should know how to localize….but well here is the question: the attending cuts out something and puts it straight in front of my face and asks me: “what is this I just cut?”

me:….(damn this looks like a nerve but why in the hell would he cut a nerve…arent we supposed to preserve them at all costs???)  hmmmm this may be part of the cremasteric fascia….(throwing stupid random scientific names just do not work by the way)

attending: nope…so what is this? what does it look like?

me: (damn this looks like a damn nerve or at least a vessel, but if I say nerve or vessel, he is gonna kill me on the spot and ask me if I think an attending surgeon in his right mind would ever cut a nerve…) 

 attending: it’s the ilioinguinal nerve that I just cut….are you blind!!!

me: (confused and thinking why the h…did he cut that nerve???)…..oh yes sir….

 It turned out that many surgeons choose to take that nerve out of the way from the beginning because it just makes their surgery easier. The loss of that nerve is only accompanied by sensory loss in the inner thigh which eventually comes back after several months….

Pimp question during formalization of right BKA: why is this anuric guy’s bone so fragile?

This is another pimp question I was asked during the formalization of a right BKA in an anuric guy who had chronic renal failure and was on dialysis:

CR (chief resident): so have you noticed how in a bad shape his bones are? Why do you think that is?
me: (thinking: here we go again for pimping firing squad #2)…hmmm because he is malnourished….? because he has osteoprosis???
CR: yeah possibly but he is way too young to be this bad in shape with his bones…so what else?
me: err….
CR: ok…I know you have been standing for 3 hours holding this leg and blood is not getting to your brain but you know the answer…just think about his biggest problem….
me:…he is anuric…he has kidney disease….
CR: bingo… so what…. ?
me: hhmmmmm…(light) he has chronic renal failure and in people with chronic renal failure you have renal osteodystrophy, that is, you have high phosphate and low serum calcium…with low serum calcium, your parathyroid glands are activated and start secreting PTH to increase serum calcium and the way PTH does that is by taking the calcium away from the bone and dumping it into the blood to compensate…that is why his bones are so fragile

Always think about your pt’s biggest diseases …dont look for zebras at first…people wont pimp you on zebras they will pimp on things you know but that you cannot connect the dots together unless you fully understand the mechanism….or they will ask you in such a way that will make you confused because you are just not used to be asked about this topic from this angle….

Pimp question during formalization of Right BKA: why is this anuric guy bleeding like this???

Hi there this is my first post, I am a third year medical student in the US and although at the end of my third year I thought it would be a great idea to write about pimp questions that you (if you are a medstudent too) will probably be asked too. So how about you learn and memorize the answers in advance? 🙂 Than you’ll just look like a star…I wish someone had done this for me 😥

Ok so today I was in surgery doing a formalization of a right BKA on a guy who had a h/o of PVD, HTN, was anuric and was undergoing dialysis…my chief resident (CR) suddenly asked me:
CR: So have you noticed how much this guy is bleeding? You have any idea why?
me: err…..because he has atherosclerosis (what a stupid answer in retrospect)
CR: that would make you think that he shouldn’t bleed much right?
me: err….hummm…..yeaaahh……
CR: so why is he bleeding?
me:…..hmmmm because he has venous stasis and blood pools down in his lower extremity and maybe that is why he is bleeding like this?
CR: ….not what I wanna hear…so why is he bleeding?
me: ……(heart pounding faster and faster)….hmmmm…err
CR:….ok think about his two biggest problems….
me:….PVD and he is anuric
CR:….here we go… so PVD is out…so how is being anuric linked to his bleeding problem?
me:….(light in my head)….because when you are anuric you do not excrete uric acid out of your system and an increase uric acid in your serum is linked to a decreased platelet count and that is why he is bleeding so much
CR:…so you knew it…too bad it was so laborious I almost lost patience….now keep that leg still….

So yeah if your CR asks you why an anuric guy going through dialysis is bleeding like hell, the answer is that he has an increase in serum uric acid that is associated with low platelet so coagulation is messed up and you bleed excessively

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