I am, with laudable restraint, not going to tell the latest story about an ER mis(sed?)diagnosis. Suffice it to say that even attending surgeons were going out of their way to look at the scans and read the notes and laugh at it. Actually, sadly, I think we’re laughing to distract ourselves from the patient’s truly tragic situation. As the primary service, we can’t avoid dealing with it; and it’s not pretty. But I’m encouraged not to join in the scoffing by trying to figure out what I, personally, would have done differently if I’d seen the patient at the beginning; and I’m not sure I can think of anything, other than a wild shotgun approach to every elderly patient with a vague complaint; which is definitely not a good conclusion. It’s easy to look down our noses, too many hours later, and with all the tests in, and the surgery completed; but had we been consulted, even six hours sooner, we might have missed the diagnosis as well. Too bad that the patient had to start circling the drain in a full-blown syndrome before the lightbulbs clicked.

Yesterday I got to do my first-ever arterio-venous fistula (used for access in dialysis patients). It was with the most legendary attending at this hospital, the one revered by everyone, and feared by most of the residents. As one of them told me, “Operating with him is like eating spinach. It’s good for you, and it makes you stronger, but it’s not a whole lot of fun at the time.” Several senior residents, hearing that I had somehow drawn a fistula with him, stopped to share stories about his teaching methods in the OR.

Suffice it to say that, concerned as I had been to start with, they certainly succeeded at putting the fear of God into me. I spent an hour in the library reading everything I could find on the subject (not much, actually, for a procedure so commonly done), and memorizing the name of every venous branch and tiny cutaneous nerve in the arm. (Did you know that anatomy books never show arteries and veins in the same drawing? What kind of good does that do?)

At length, I showed up for the case. The attending gave me the kind of look that interns get when they show up for cases over their pay grade with attendings who were previously blissfully unaware of their existence. “Have you ever done a fistula?” No. “Have you assisted with a fistula this year?” No. (Not an intentional omission; although truth be told, these things only have room for two people; even medical students rarely watch or assist on them.) “Do you have any loupes? [special magnifying glasses]” No. “Have you ever sewed with 7-0 suture?” No. “All right then.”

I don’t know whether my studying paid off with some semi-sensible answers, or whether he gave me up as a hopeless case, because he did very little of his usual badgering. He did, however, let me sew the entire anastomosis, in 7-0 suture, with no loupes. (This suture, although actually a decent size for cardio/vascular surgeons, who can get down to 9-0 and 10-0, is small enough that the middle-aged scrub techs have to hold it five inches from their face in order to be able to see to load the needle-drivers.) It was also the first time I’d held vascular instruments (which are extremely delicate, and configured entirely differently from the usual needledrivers, pickups, and scissors). So I think that means I did a good job.

Unfortunately, I think I also fell in love with vascular surgery. Silly, Alice, why did you go and do that? I thought you hated watching the endovascular cases. Well, just watching; they might be fun to actually do, the way all the pieces slide inside each other and inside the patient like a watchmaker playing Russian dolls. I thought you were going to make a wise lifestyle decision this time, instead of falling for a specialty which, of all others, is guaranteed to get you up at night with genuine emergencies.

But those blood vessels are beautiful; and that tiny suture slipping into the right place, with those itsy-bitsy needles – ahh. The way the delicate thin vessels magically seal against the pulsatile blood flow because of your stitches. . . The multitude of different surgeries you can do (vascular surgeons, unlike the rest, never ever run out of options.) . . The analysis and decision-making involved in even a “simple” case like a fistula . . . I thought I didn’t like invisible suture and stitches so small that even steadying your elbows on the table is barely controlled enough. . . guess I was wrong about that.

I’m trying very hard to hold on to my original appreciation for plain general surgery, or if not that, then some specialty with decent hours. But now I know why half the residents at this program plan on doing vascular surgery. It probably also has to do with the best attendings, at this program and others, being vascular surgeons.

Addendum: I henceforward swear not to mention stories about the ER, at least not on this blog (I’m afraid interagency sniping is a fact of life in the hospital). After I wrote the above an ER friend called to chat, and to vent about her own frustration with a different surgical team at my hospital who last week, by her description, grossly misdiagnosed a patient of hers (although higher levels intervened in time that the patient is doing as well as possible). So actually I guess the score between surgeons and ER, for diagnosis and correct management, is still even. I’m just going to stop talking about this at all. (Funny, though, I trust my friend, as an ER doctor, more than I trust a few of the surgery residents, as surgeons. I believe her version of events. I wonder if it would have changed anything if I’d been the intern she called, instead of someone else; if having a real relationship between the two sides would have improved the exchange of information.)