absite as myth

I’ve been thinking: the surgery in-training exam is really like a recitation of legends, orally recounted histories, not too closely related to facts, that define our community.

The test runs through a long series of stories, which are so familiar to surgeons and surgeons-in-training, that we only have to mention a few words of the story, to have the whole thing immediately recognized and understood.

These are some of the legends: gallbladder cancer, incidentally discovered after lap chole, invading through the lamina propria (snap answer: resect a surrounding rim of normal liver tissue); projectile vomiting in a 4wk old male (pyloric stenosis, hypokalemic hypochloremic metabolic alkalosis); medullary thyroid cancer (MEN 2; check for pheochromocytoma before resecting); knee pain and blue toes in a 50-yr old smoker (popliteal aneurysm; resect and bypass, and check for a contralateral aneurysm and AAA); mesenteric thickening after total colectomy for FAP (desmoid tumor; chemo only, no surgery).

That isn’t even English, and it certainly bears little relationship to what we actually see and do; but those are the legends that we all recognize. In that light, the ABSITE is an exercise in intergenerational transfer of epic tales. . . like the Iliad and Beowulf and Hansel and Gretel. . . That’s my explanation for the high incidence of rare diseases, the lack of correlation between what we practice in real life, and the right answer on the test, and the way the residents go around for a week afterward trading key words and comparing answers. This is our oral tradition.

 

discretion

I had to calm one of the medical students down the other day. We were in a crowded elevator, and he was carrying on the conversation we’d started before getting on, about what he’d liked about the surgery rotation so far.

“I got to see a craniotomy the other night on call,” he exclaimed. “They let me touch the brain! It was kind of squishy.”

In the middle of the elevator. Full of visitors.

 

recognition

It’s kind of touching when patients and their families notice the hours we’re working.

The service I’m on right now is particularly opportune for this, since the attendings start operating so early, and demand such detailed knowledge of the patients by the residents, that the entire team (intern, resident, chief, couple medical students) has usually come through each patient’s room, severally and ensemble, by 6am every day. Which is certainly annoying, but also noticeable.

In the course of the day we’ll round with an attending. Then we all also come through around 5-6pm, as well as the intern multiple times in between. The people who aren’t completely asleep, or completely absorbed in the TV, can’t help noticing that we’re there around the clock. They also notice that the same small group of us is there virtually every day of the week. They’ll comment, after one of us has had a day off, that they’re glad we got to sleep in. (They didn’t, though, because someone else was in just as early. . .)

One patient has run the entire gamut of the service: preop admission to the floor, postop transfer to a monitored floor, and now in the ICU (don’t ask me why the downward progression; we wish we knew). The family has been so polite; asking the right questions, but also not pestering us when we give our best explanation, and admit that there are things we can’t explain. They’ve also been commenting on the amount of time we spend in the hospital. One of them asked me today if I’ll be off for the weekend, and I said no; he was interested and inquisitive, so I told him the 4 days/month rule; which sounds shocking, when you say it out loud to a person with a semi-normal life. We see it in contrast to the old rules (or non-rules) so to us it sounds good; but although I will, rarely, tell patients and families about 80 hours and 4 days, somehow the old rules seem like a secret that belongs inside the clan.

Which is strange, now that I write it down. Because people do expect their medical providers to be available 24/7 (or to have a thoroughly informed colleague covering), and yet on a personal level, they’re surprised by our lives.

At any rate; it’s nice to be thanked, every now and then.

 

in review

I’m going to try not to comment on this too frequently, as I get to operate more. But:

I had a case the other night. I did most of it myself. Being as objective as I can manage, I think I did not do it too badly, perhaps even very well at some points, but overall I was certainly slower than the attending doing it all himself would have been.

Now, a few days later, the patient is struggling through the post-op period. Nothing frankly technical (no vascular bleeding, or suture lines falling apart) – but I can’t stop going over the case again and again, trying to decide, definitely, whether if I had tied those knots faster, or run that suture line more adeptly, or not crossed that one tissue plane that we weren’t supposed to cross, would he be doing appreciably better now? Or was he just a sick man having a high-risk operation, and the current problems are no more than were bound to result anyway? Really, actually, I think I probably only added 15 minutes to a 4 hour case. But I operated on him; I cut on him – and now he’s sick. . .

This is scenario is replayed for every one of my patients who encounters what, last year, not operating, I would have regarded as a common and inevitable post-op complication; a bump in the road. But now, I touched the patient; I more than touched them; I was cutting things up; and now things are not perfect.

my fault – my fault – my fault

 

baby steps

The last few months have seen me being allowed to operate far more than previously. My performance in the OR seems to consist of occasional stretches of competency, mixed in with a good many more episodes of apparently completely failing to grasp what I’m being told to do.

So I rather enjoyed the other day, when, after about six hours of operating with one particular attending, we came to a crucial and difficult step, deep in the abdomen, close to the aorta. She was just starting to try to explain the maneuver, when I had a sudden flash of insight, and, building on a couple of moves she’d been trying to teach me all day, completed the step, much faster than either of us had anticipated. She exclaimed, “Where did you learn to do that?” “You taught me, earlier today.”

That was fun. Wish I could do it more often. Usually it’s a much slower process, with the attending repeating, “[unspoken: as I’ve already told you five times in this case] don’t move your hand like that, do it like this.”

 

second chance

I admitted a patient from the ER one night over the holidays. The ER called with a CT scan showing diffuse pneumatosis, and the most obvious portal venous air I’ve seen so far. The patient himself looked far better than the scan, and was amazingly comfortable, considering that he had a heart rate of 140 and was already in acute renal failure. He was so comfortable that it was very difficult to persuade either my attending, or the patient, that he needed emergency surgery. (“Pain out of proportion to exam, Alice. You can’t tell me he has ischemic bowel and no pain.” I insisted, so we didn’t really lose any time, but it was a little disconcerting.)

As for the patient, that was the worst conversation I have ever had to have. Telling a family that someone died is easier. Telling a man who’s chatting happily that he’s almost certainly going to be dead within 24 hours is nearly impossible, either to find the words, or to convince the patient. I had to not only convince him that matters were this serious, but also discuss the option of surgery – his only chance of survival, but a very slim one, with a significant chance of a long ICU stay and major morbidities, if he did survive. (Some might say that with that CT scan, we shouldn’t operate. 1) You can see pneumatosis and portal venous air from a bad bowel obstruction, which can be salvageable. 2) He was relatively young, and with few comorbidities. We never did figure out what caused his ischemia.)

In between talking to him, I was calling the chief and the attending and the OR and the ICU, getting iv fluids and antibiotics running, and moving him to preop holding. Not much time. No sooner had I settled him in preop, with a nurse to watch, and the attending about to walk in, than the trauma pager started going off with multiple gunshot wounds, so I had to leave him. Three hours and several traumas later, I found him and the chief resident in the ICU. The operation had been completely unsuccessful; there was absolutely nothing to be done. His body was shutting down, and there was barely time to have the family at the bedside before he died.

I felt awful afterwards. Not just because it was the holidays, and we had lost a previously healthy man suddenly, but because I had spent half an hour talking to him about his death, and had never talked about what would happen to him after death. I had watched somebody dying, and had never even mentioned God or heaven or hell. Which meant that I did him exactly no good at all. He died, as I knew he would, and had to face eternity, and I hadn’t even mentioned it.

Yesterday one of the PACU nurses came up to me. (At night PACU and preop are staffed by the same nurses.) “Remember that man with the ischemic bowel who died? I went to the funeral home. I had to tell his family something he told me that night. He said, ‘I’m not worried about this, because I’m putting it in God’s hands. He took care of me when I had surgery 30 years ago, and he’s taking care of me now. If he wants me to live, I will; and if not, it’s all right. If I don’t make it through surgery, tell my family I’ll see them in heaven.’ ” I started crying in the middle of PACU. He’s safe, after all. I didn’t do anything I should have, but he knew better than me. Next time, I won’t make the same mistake.

(As for the nurse, I have a whole new respect for her, going out of her way to comfort not only the family, but also the other caregivers.)

 

theory of relativity

My perspective on time in the hospital has certainly changed in the last two and a half years. I remember, even as recently as the end of my intern year, watching the clock intently as the end of a shift got closer, and being very antsy if something came up at the last minute to prevent me from leaving. I also used to spend a good deal of time pondering my days off for the month, and exactly when they fell, and how far apart they were.

I don’t pay as much attention to those specific times any more. I come in as early as I need to so that I can round on patients to my satisfaction. (To me, that means reviewing all the drips on ICU patients, reviewing and correcting all labs, and reviewing the most important consultants’ notes [for me, infectious diseases], before signing in with the team.) I stay as late as necessary to tuck my patients in for the night, and make sure that I’ve checked the intern’s orders from the day. If a case is running late, I expect to stay late with the chief, and don’t pay too much attention to the time. The work is becoming more important, and the time less important.

Which is actually less stressful. It’s almost more peaceful, not thinking so much about time of day. Of course, the corollary is that I’m so busy I scarcely look at the time except when I need to date a note, or in terms of figuring out how cases are running in the OR (usually not that important; our OR is so chronically slow and late, there’s always time to do another chore before the next case starts).

As for days off, after pulling a couple stretches of four weeks straight (between one month and another), working two or three weeks straight through isn’t such a big deal anymore. Four weeks, though – I was definitely getting pretty crazy by the end of those. That was more definitely dangerous for patients than working 30hrs straight.

You get acclimated to anything, I guess.

 

not just a test question

Steering back to safer, less political waters:

I’ve been having a peculiar experience lately. Of course I’ve grown inured to the embarrassment of concluding that a patient needs surgery, and making my case, and then being informed by the attending that I’m insane, there’s no such indication, and the patient is best left far outside the OR.

But recently, I’ve encountered the slightly more disconcerting phenomenon of being told by the chief resident that the patient doesn’t need surgery, adjusting my presentation when talking to the attending, and then being told by the attending that we should book the case for first thing in the morning. Depending on how much I caved to the chief, I then get reamed out by the attending, again, or I get credit for having made the call.

Last night was a succession of such cases. A large bowel obstruction, a variety that I haven’t seen a lot of, which people weren’t convinced was really obstructed, but the attending agreed with me. Ischemic bowel, which the intern and the ER doctor were trying to downplay as questionable, but I knew the CT was incredibly bad, and the patient’s vitals and appearance were subtly hinting at the outcome, which was that he died six hours later despite our best efforts (I can at least be glad that I didn’t waste time, and that I stuck to my interpretation enough to drag both the chief and the attending in much against their wills). A less obvious case of ischemia in a vascular patient, requiring intervention in the middle of the night. . .

Now that I’ve gotten to the seniority, and perhaps the reputation, that the attendings will usually, despite questioning me at length, book the case immediately just on my say-so (because surgeons can’t function without interrogating each other, and especially their junior members, regardless of how correct the plan is), I’m starting to encounter the weight of responsibility: I have the OR set up, the patient consented (often after being talked into it quite urgently; so that I would feel incredibly guilty if I had persuaded them so firmly, and was mistaken) and carried down to preop. Everything ready to go for a major operation, and all on my authority. I make time, no matter how much the ICU is calling me, to wait till the attending comes, so I can see what he thinks of the patient and the CT scan. I only ever once got the patient and the attending together in holding, and had the attending seriously consider cancelling. But I get very nervous at the idea that I, virtually by myself, am setting people up for big surgeries. . . what if I get it wrong?

 

the early results of Obamacare

I’ve been trying to avoid talking about health-care reform (or deform, if you want to be accurate) on here, because it makes me so angry that I’m virtually speechless. I’ve also stopped talking about politics with my liberal friends at work. I used to enjoy a friendly debate, but there’s nothing fun about the looming disaster.

I can’t not talk about this any more. I just opened a mass email to all the physicians at my hospital, informing us that, in addition to compazine (a very basic anti-nausea medicine; cheaper and more effective than zofran, and less sedating than phenergan; my go-to drug for post-op nausea) and some iv narcotics, and antibiotics, there is now a national shortage of propofol (the fast-acting sedative used to induce anesthesia for a general case, used as almost the sole agent for a conscious-sedation outpatient procedure, and relied on heavily to sedate ICU patients, because its very short duration of action means you can turn it off quickly to check for neuro status, and trials of vent weaning, and get it back on quickly if needed), and we are going to be using the European variant, whose key features are that people who are allergic to peanuts can’t have it, and it doesn’t have the same anti-microbial agents built in, meaning it’s more liable to acting as a culture tube for bacteria.

I can’t see any explanation for this sudden, simultaneous shortage of all kinds of basic drugs (which I have never seen before in my career; one at a time, maybe, and usually more rarely used drugs) than that pharmaceutical manufacturers are scared stiff of the antics in Congress, and are trying to cut their losses by not manufacturing surpluses when they can’t tell if they’ll get paid properly in the near future.

In other words, it’s starting to feel like a third-world country (or maybe just Europe) and they haven’t even settled on which gigantic, mysterious, debt-riddled, unworkable socialist plan they’re actually going to force down our throats. (Anyone else seeing this phenomenon too? Any less depressing explanations?)

60% disapproval rating across all polls, and it’s still full-steam ahead? Who still thinks Obama gives a rat’s — what the people really want?

Although I have to say, since a majority of the American people were idiots enough to vote for this traitor, after having heard him advertise his socialist agenda loud and clear for a year’s worth of campaigning, it’s their own fault that he’s now giving them exactly what he promised. (And I say traitor because I mean it, in the sense of someone who’s committed to the destruction of Constitutional government and the traditional American way of life, and perhaps even national security. Think KSM trial in New York.)

If any non-medical people are reading this, and if you’ve been wondering what the medical profession thinks of Obamacare, I have two remarks for you: the AMA does not represent us, and we haven’t been screaming simply because we’re too busy taking care of patients, and too despairing of being able to stop this railroad crash, to try to express our fear and disapproval. (And a minority of us are socialists, don’t ask me why.)

Guys, this is how freedom is lost: we’re celebrating Christmas, we’re not watching, and Obama and his socialist cronies in Congress are about to transfer 15% of the national economy to government control, after having already taken banking and finance. . . this is going down fast. I’m glad I got to at least see America as a free nation, although I guess I won’t get to spend much of my grown-up life in that country. . . If I wanted socialism and multiculturalism gone crazy, I would move to Europe. . .

Merry Christmas.

 

teachers

It’s starting to dawn upon me that all the chiefs and attendings I’ve found very annoying or stressful have actually been teaching me a great deal. Most of them, because it was their personal demand for excellence and thoroughness which was irritating me; a very few, because their laziness was forcing me to take more responsibility for being the thorough member of the team.

Too bad that it usually takes me six months after a rotation to realize what any particular chief or attending taught me.

But I recognize now that my regard for getting some degree of social history; my attention to looking at all the available imaging; my goal of knowing absolutely all the details of the medical history before calling the chief or attending; my thinking about electrolytes in the ICU; my thinking about DVT prevention – they all came from chiefs and attendings whom I found nearly intolerable at the time – because I wasn’t yet prepared to think that hard or that thoroughly about “only” a surgical patient.

Now if I can just think of that when I’m getting annoyed at someone. . . what is it that they’re teaching me?

I remark on the above, in order to avoid relating in detail how extremely annoyed I am at an ER resident and attending, who called us ten minutes before signout with a claim of appendicitis, on a college-aged female, without obtaining a white count, a pelvic exam, or a CT scan. I’ll grant that the CT scan is probably unnecessary. But they seriously seemed to expect us to book the patient for the OR without knowing any lab values, and without anyone having done a pelvic exam. (She had pain, but no peritonitis.) Please tell me if I’m mistaken, so I can stop being annoyed at them; but in the real world do ER physicians call surgical consultants without either a CT or a pelvic, on a young, sexually active female patient?

(I’m sure they’re teaching me how to be polite to frustrating referring physicians. . . like the PCPs whose first test for gallbladder disease is the HIDA scan. . . I haven’t quite learned it yet.)