October 2009

Now for some non-concrete thoughts.

I dislike Halloween. I especially hate yard decorations. For one thing, do you know how eerie a fluttering ghost or witch can be when you’re driving by in the dark, early in the morning, barely awake, trying to get to the hospital?

For another, I think covering your house in Halloween images is downright foolish. Witches, for instance, are not benign jokes. Sure, many self-titled witches today probably can’t accomplish much of anything. However, that doesn’t mean the concept isn’t real. In the Bible, for example, the witch of Endor summoned the spirit of the dead prophet Samuel, who accurately foretold King Saul’s death in battle. In general, the idea of trafficking with Satan should not produce warm fuzzy holiday thoughts. (And even if you want to talk about different kinds of magic, in the end any real magic, in this world, comes down to the same thing: rebelling against God’s providence and trying to control Nature and events through your own power.)

Ghosts? Only in modern American cotton-candy thinking are ghosts friendly. I don’t believe they actually exist (as opposed to witches, who are at least a theoretical/historical possibility); “it is given unto men once to die, and after that the Judgment.” But if they did, they have been portrayed from time memorial as unhappy spirits, either trying to escape from an unpleasant afterlife, or with some vengeful business to accomplish. There’s a reason haunted houses have been viewed with terror. Why would you try to bring that atmosphere to the house you live in?

Jack’o’lanterns: designed to scare evil spirits away from the house. Also not originally funny.

Spider-webs: yes, personally there’s nothing I detest more than a real live spider, no matter how small. So my view may be skewed. But are any of you really fans of spiders in the house? So why drape giant ones over the outside of the house?

In short, people who celebrate Halloween, and especially who decorate enthusiastically for it, are demonstrating a breathtaking lack of imagination. For a Christian perspective on the reality of evil and the supernatural, and its potential for devastating intrusions into the everyday, try Charles Williams’ Descent Into Hell or All Hallows’ Eve, which could be described (by extreme oversimplification) as a ghost story and a zombie story, respectively. For a (slightly) more upbeat approach, still involving a powerful and evil wizard, read War in Heaven, which is my favorite of his seven supernatural novels. (For those of you now questioning my literary taste, these are nothing like the current pulp vampire toxins flooding the market. Charles Williams was once a dabbler in black magic, who then converted to Christianity, and was a member of the Inklings, along with C.S. Lewis and J.R.R. Tolkien. So he knew what he was talking about, and he wrote as only an Englishman trained to write Latin verse from childhood can write English.)

Surgery requires concrete thinking because, among other reasons, there’s no room for fudging in the OR. In order to do anything – literally, to do anything at all – in surgery, you have to ask for a precise instrument from the scrub tech. You have to know what you intend to do, and exactly which instrument you need to do it with. For reasons of both protocol and expediency, you can’t just fish through the instruments on the scrub tech’s table (can’t take your eyes off the field for so long; the table is out of arm’s reach; there’s such a huge collection of metal instruments in trays there that only the scrub tech knows where anything is; it’s very impolite to take one of the scrub tech’s instruments without asking for it; most scrubs will be eternally furious at you if you so much as touch the mayo stand instead of asking).
At the very beginning of internship, if you’re actually expected to do anything other than not get in the way during the surgery, the attending will be the one asking for the instrument and telling you what to do with it. But early on, they transition to expecting you to make at least a few simple decisions about what to do next, and what to do it with. Even the most mild-mannered attendings can go to town on the resident who doesn’t know which instrument he wants to use: “What are you going to do next, doctor? Are you going to stand there all day? Do you want to mobilize in this direction, or not? You sure you want to cut across that artery without ligating it first? Come on, doctor, your patient is bleeding; what are you going to do about it?”
So it becomes an ingrained habit of thinking: you plan ahead to accomplish a particular thing (peel the hernia sac down; get the gallbladder off the liver bed; separate the strap muscles), and you choose how you’re going to do it, and then you give instructions to the scrub tech to help it happen. No ifs, ands, or buts.
(Although there is a certain amount of leeway for not being able to name the instrument, as opposed to not knowing the shape or type of instrument you want. Choosing metzenbaum scissors vs bovie is important. Forgetting the exact name of the clamp, or not being able to pronounce it, may not be fatal, as long as you can quickly describe it enough for the tech – who probably knew what it was before you thought of it – to hand it to you. This exception does only apply for about the first two, maybe three times, that you’re in a procedure. After that, if you’re using it, you should know the name.)
(And yes, there is also a certain amount of puzzling your way through distorted anatomy. But even then, you have to at least decide which area you’re going to tackle first, and how you’re going to do that.)

Somebody on a tv show the other day was cutting with the back side of a scalpel. It was a nice big #10 blade, the fat round wide kind (nice, because they slice things right open without the slightest effort), but they were cutting with the back side, which isn’t sharp, and it made a big incision that bled tv blood. I found that very annoying. If you got enough of a scalpel to use as a prop, wouldn’t you notice which side was sharp?

In the surgical world when we cut our hands we don’t use bandaids. You can’t scrub with a bandaid, and you aren’t supposed to scrub with an open wound (more I think because of the increased risk of infecting yourself if the glove is broken, than for the patient’s benefit); and of course you can’t not scrub at all just because you were silly enough to cut your hand. So we use the little plastic tapes that are used to stick ivs down. They’re slim and smooth, and are actually sticky enough that you can scrub for two minutes with one on, and have it stay on through gowning up.

I know this, because somehow, although I think I’m getting to be not bad in the OR, I cut myself frightfully often with kitchen knives, and even with all kinds of objects that you wouldn’t think were sharp, but somehow I end up with cuts anyway. I’m a little disturbed by how awkward I am with everyday objects; but I know I’m not that clumsy in the OR. . . I guess I’m concentrating more there.

Anyway, it’s gotten to the point that I keep a small collection of iv bandages handy, for taping up my fingers.

I’m nearly done with a third of the year spent in cardiothoracic surgery, and I’m counting down the days till I get back to general surgery. People keep asking, and I’m completely unable to explain why; but somehow, the strange fascination that drew me into surgery in the first place makes me most interested in general surgery. I’m looking forward to getting called to the ER to see people with appendicitis and cholecystitis and diverticulitis and abscesses. That’s weird, isn’t it? The CT guys keep telling me their stuff is cleaner – nothing too dirty or smelly in the chest – but somehow it doesn’t get my attention. Maybe because I didn’t ever spend much time with this in medical school, so it never seemed like a part of the real surgical world to me.

Nevertheless, despite having been anxious to be done with the rotation for the last two months, I’ve learned a lot.

- I’ve come to see the heart as a real object, with definite anatomy, and implications of that anatomy for patients’ health. Before, coronary artery disease was a nebulous kind of entity to me, and whether or not a heart attack occurred seemed just as rational as lightning striking. Now, I can read a cath film with some degree of accuracy, and the fellows finally succeeded in pounding into my head the difference between the acute marginal and obtuse marginal branches, between the diagonals and the septals. They’re as solid and real now as the superior and inferior mesenteric arteries: if you block any one of them, the tissue downstream will die.

Similarly, ejection fraction on an echo makes more sense, and the different valves that can be stenotic or regurgitant, and the different types of heart failure that will result.

- I’ve looked at a lot more chest x-rays and chest CTs, and I no longer skim through the lung windows of a chest CT as though they were a gray blur. I finally grasped what ground-glass opacities look like, and bullous emphysema, and some of the distinction between atelectasis and pneumonia.

- I am really good at arterial lines. After weeks of doing a couple every day on cardiac patients with poor peripheral circulation and/or no pressure and/or no pulsatile flow, the radial artery on a patient who’s only hypotensive seems to leap out. Radial lines used to be my least favorite line, and now they’re fun.

- The critical care attendings and the cardiac attendings, in between constantly disagreeing with each other about what pressor is good for what problem, at least taught me the actions of all the different pressors (not just the three most common), and a philosophy of choosing them rationally rather than at random. (I’m just ashamed it took me till third year to get this.)

- As the senior residents promised me all last year when I got too excited about what they considered to be a minor amount of blood, having seen blood pouring out of the heart when it’s being cannulated, having seen an ascending aortic dissection visibly expanding while we were struggling to get the axillary cannula in, having seen four liters of blood cleaned out of an open chest, having seen chest tubes drain one liter in two hours – I have developed the most shocking disregard for an artery or two shooting at the ceiling, or a central line site oozing continuously, or a vascular surgery wound soaking through a couple packs of kerlex. On the other hand, I have a new respect for the power of plasma and platelet transfusions, active rewarming,  calcium infusion, and patience, to correct severe coagulopathies, without the need to operate on bleeding that you couldn’t really improve surgically.

- This skill will probably rarely be of use again, but I am a chest-tube-pulling machine. I can get an armful of supplies, and have ten chest tubes (ok, two per patient) out in half an hour, with no assistance, and no air leaks. Only valuable when you have an ICU full of post-op day 1 heart patients, or an entire list of post-op day 1 VATS patients, but it’s fun to surprise the patients with how easily it goes (usually). Trauma has a few chest tubes, but not this quantity, and by the next time I’m on trauma, I’ll be senior enough to tell someone else to pull the chest tubes. Maybe.

I take back what I said about the janitors and cooks and garbage men having jobs as demanding or exhausting as doctors. Actually we’re quite different. This job doesn’t stop when you go home. Even in this era of sign-outs, and cross-coverage, and restricted hours, the job doesn’t stop when you leave the hospital, or when the clock says you’re off duty.

I’ve spent the last five days, missing meals and sleep at the majority of meal-times and night-times, not because I was required to, but because I couldn’t not. I felt obliged to do some “extra” things – double-check this or that; spend extra time making sure an NG tube was in smoothly, or that there was iv access, or that an xray got done and looked at immediately, before leaving the hospital; driving back in – and back in, and back in – to see people whom I knew logically were just fine, didn’t need me — but I couldn’t guarantee 100% for sure that something bad would not happen, because I had wanted to sleep instead of checking on something. So I checked.

There were times when I could have chewed out a resident from another service, told him to stop being an idiot, take a look in an anatomy book before calling a surgeon to say such silly things, if that’s really how little he remembers from medical school, and do his own work for a change. But I didn’t. I explained politely how impossible his idea was, then told myself that I couldn’t be 100% for certain that he was wrong and I was right, and it would be unforgiveable if the patient got hurt because I was having a turf war. So I went and did his job for him, and wrote a polite note saying a surgeon wasn’t needed.

The point is not that I should have skipped any of those things: they were plainly my duty. But they’re not in the job description, and they have nothing to do with whether or not I get paid. When I go home, I can’t stop thinking about this job, and the nurses don’t stop calling me just because I left. My professional duty obliges me to do all kinds of things that are not part of a timed job.

Like talking to the family of a patient who died. He wasn’t on my service, I wasn’t really there for the death, I still can’t figure out how I ended up being the one doing the talking. But I know I’m the only one of all the doctors involved who knew him as a person, before he was just a disaster that we were working on; and I myself am sad that I can’t ever talk to him any more. And so I went and spent time with his family, all of them in various stages of grief: some unable to talk, some angry and trying to blame me because I’m “the doctor,” some being logical and wanting detailed explanations. . . and the air in the room so dark it was hard to breathe. . .

I didn’t really know what they meant when they started talking about professionalism in medical school. Now somehow I’m here. I don’t know if I was always this obsessive and paranoid (I can’t call myself dedicated or thorough; maybe someone else will, some day); but I am now, and I have to be, and there’s a compulsion inside me, that I caught from the doctors who trained me, and I can’t not act this way.

As if reading about the Baucus healthcare “reform” bill making it out of committee in the Senate wasn’t depressing enough for one day, I was paying my bills this evening, and made the mistake of reading the “newsletter” that the electricity company sends with the bill. Apparently, the state legislature passed a law requiring electricity companies to decrease consumption in their areas by 1% in the next year, and 3% in the next three years.

I ask you: how is the electricity company supposed to decrease consumption? Aren’t I the one doing the consuming? How can the government mandate a third party to change what I’m doing? Personally, I already try to keep my electricity consumption down, simply because I hate spending money unnecessarily. Now that I’m the one writing the checks, I’m a worse fanatic than my mother ever was for turning off every light except the one I’m using, and keeping the heat or air conditioning as low as possible (to tell you how crazy I am: I wear a jacket nearly all the time at home because it saves $50/month in the winter).

The newsletter went on to explain various programs that the company is enacting to reach this goal. Blah blah, very nice, not applicable to me, and wouldn’t make much difference to me if I were a bigger consumer. Then the punchline: these programs are going to be paid for by an extra charge on the bill. So despite the fact that I already use a minimal amount of electricity, and will not be using any of these programs to encourage decreased consumption, the state legislature just increased my electricity bill. Basically, in the name of saving the environment (which doesn’t need saving, and I’m not the one hurting it), they just took some more of my money; in addition to the property tax and income tax bills that arrived in the same mail, and the school taxes, and the gas taxes. . .

I can’t win. The harder I work, the more of my money the government wants. Even if I live frugally and try to conserve resources on my own, I still end up paying for the people who don’t. Seriously, folks, if Obamacare passes, I’m not going to waste money on getting my license once I finish residency. The amount of impending paperwork for decreasing monetary returns is soul-crushing. . . One of the residents is reading Atlas Shrugged, and was raving about it to me today. . . I think I would only get more depressed if I read it: the vision of an unattainable, unrealistic ideal of personal responsibility and freedom would be so far from the European-style socialist morass that our country is devolving into.

When I was a medical student and there was a VIP patient, I and the rest of the medical students were carefully herded away. If it was in surgery, we weren’t allowed in the room, and only caught glimpses of the patient during group rounds. On medicine, I seem to remember the attending and a senior resident rounding on the patient by themselves, without the rest of the team at all.

Now, a VIP patient means I get reminded by several different people (chief/fellow, attending, nursing supervisor) to pay immediate attention when the patient reaches the ER or the floor, and I had better have every detail of their history and current condition memorized for all the people who are going to ask me about it. I won’t get to touch anything sharp in the OR, but I’d better be there to help set everything up.

In my experience so far, doctors and their relatives are the best behaved (once they’ve decided to let go and let someone else handle it; otherwise, troublesome); nurses are impossible to manage, since they quite frequently refuse to do what you tell them to (basic things, like walk and take deep breaths), and want to do all kinds of things you’d rather they didn’t; CEOs and their relatives are fairly well-behaved, just incredibly stressful.

The worst one was a former CT surgeon, with a temper to match, who had open-heart surgery, and then I got to take the drains out afterwards. Predictably, my method didn’t coincide with his method, and I heard about it. . .

Hurricane Jill has pinpointed it much better than I’ve ever managed: Surgery is black and white. Either the patient needs surgery, or they don’t need surgery. Either it happened, or it didn’t happen. Either you cut a particular structure, or you didn’t. Jill contrasts this with her pharmacy background, but I think it also contrasts with other medical fields: you can debate which antibiotic has the best coverage, or which beta-blocker works best for CHF patients, and apparently the medical interns at my hospital can even debate how much potassium to give a patient who’s hypokalemic (to me it’s a reflex that happens as soon as the labs come back); you can adjust the insulin coverage gradually, and experiment with different oral antihypoglycemic agents to see which work best for an individual patient. . .

Surgery is qualitatively different. Yes, there’s room for debate, and difference of opinion on the team, or between attendings, but in the end someone has to make a decision and act on it, and deal with the consequences; and usually that decision has to be made sooner rather than later. In the ER, that’s obvious; but even when a patient comes to the clinic, they and their PCP are not usually interested in spending a few months thinking about surgery. They come because they want to have a definite discussion, and make plans that day (or is that transference from our agenda? I think not; if the problem is one that can stand to be watched, the PCP has often done that already, and referred to a surgeon when the patient is tired of nonoperative management). If a patient gets started on a medication, and it doesn’t work out well, it’s not too much of a big deal to change to another one. But if the patient needed surgery, and didn’t get it, you don’t get a free pass back to the status quo ante by proceeding with surgery once you realize your mistake.

I guess it’s not so much that surgery is really black and white, or has hard, clear answers, more than any other medical field, but that even in the absence of scientific certainty, you have to make a decision. There is existential, if not epistemological, clarity. (Maybe that’s too many big words. . . tell me if I got them backwards.)

I always hated grey answers. Some questions I no longer consider important enough to be worth spending time or effort on finding the right answer to, but on the important questions, I have to have certainty. Does God exist? Yes. Is the Bible true? Yes. Should we do an appendectomy? Yes.

I was encouraged the other day to discover that I am in fact turning into a surgeon, and possibly even a competent one. The fellow had been talking me through a procedure, my first time, and it turned out quite simple and easy, perhaps a little to his surprise (I didn’t know enough about it to be surprised one way or the other).

That night I had to do the same procedure, on a patient who was not intubated, and quite jumpy. Let’s just say that it’s difficult to get good local anesthesia if the patient jumps half off the bed every time you get a 28-gauge (ie very tiny) needle 0.5mm under the skin. . . despite some iv sedatives in assistance. And of course this time, in the middle of the night, without the fellow around, the procedure was much more complicated than it had been in the morning. Also, the instrument tray the fellow had advised using contained instruments that were next to useless for the purpose at hand.

So I got to try and keep that patient calm (with the nurse’s very good help), through a procedure that lasted much longer than I had planned on, without letting on to anyone else that I had very little idea of what I was doing, or what I would do if that didn’t work. . . It did work, finally, when I was about ready to declare defeat and go looking for a better instrument set and/or someone senior to me.

Perhaps it’s not reassuring to the public to say, but to me, being able to improvise in a difficult situation, through a procedure that I’d never seen done quite that way before, means I’m learning how to operate, and how to make instruments do what I want them to do. A small step in the path of the legend of the vascular surgeon repairing a ruptured AAA with a set that turned out not to contain any vascular clamps. . . (the legend doesn’t mention whether the patient survived; I ought to ask).


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