in the OR


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

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.”

It’s been a while since I’ve had to realize that just because something looks easy doesn’t mean it really is. How many times I’ve watched from the sidelines as an attending and senior resident waded deep into the abdomen, hunting out a cancer or perforation and resecting it. For some reason, that particular endeavor, more than peripheral vascular surgery, or breast surgery, or bariatric surgery, has captured my interest. (The closer I get, I’m starting to question that interest, but that will take a while to sort out.) First I was impressed, then I started to think that it didn’t look that difficult, and surely I could do it, too.

So it has been my picture of the glory of being a senior resident to participate in a major abdominal case. I got one, once, as a second-year, but I was pretty lost, and mostly just assisting the attending. She did let me do a few key parts, and that has pulled me back for more; but I had never really done such a big case.

Until last week. The chief was scrubbed in a Whipple, so I got the colectomy. Which was fair, as I had been rounding on the patient for the last week, as the attendings discussed back and forth whether or not to proceed with surgery. The indication was a little uncertain, and the patient was far from being a good operative candidate. Textbook, in fact, for who you should go to all lengths to avoid operating on. Finally, though, circumstances forced our hand, and we decided to go ahead.

It was a little bit of a rocky start when, while anesthesia was intubating the patient, and the attending and I were reviewing the CT scan, he asked me, “So how many of these have you done?” I’m a bad liar. I hesitated for a second. “A few.” He raised an eyebrow. “Well, one actually – and a couple more, laparoscopically, on pigs.” He started laughing. “Next you’re going to tell me, none, but you dissected it in anatomy class first year of med school!”

I was kicking myself for once again being too truthful for my own good, (such a fine line between endangering the patient by claiming to know how to do something you don’t, and destroying your chance of getting to practice by admitting to too much ignorance), but when we had all the drapes up, and the suction and bovie cords thrown off, the attending, hardly glancing in my direction, said, “Let’s start” – and the scrub tech handed me the knife. First time any attending ever let me set out on my own private expedition, as it were, to get into the abdomen. No directions, no comments, as I started cutting down to the fascia; just a minimum amount of counter-traction.

It only got better from there. He discussed the next steps with me as though I had any idea or say in the matter, and then let me do virtually every bit of the work, for the next several hours. And it was work. I had thought holding a retractor for hours at a time was hard work. Not much, compared to trying to hold back six feet of intestines with three fingers, spread the mesentery with the other two, and cut with an accuracy of millimeters with the other hand. And at every step, the thought that if my hand shook, or I misinterpreted the nature of what I was looking at (harmless fat, vs. a significant vessel), I could kill the man who had put his life in my hands.

I was tired, and ready to be done a good while before the end; but of course the most significant parts – the anastomosis, and the fascial closure come at the end. The idea of doing a couple of these a day – and maybe more at night – as early as next month, and certainly for years afterwards, is a just a little bit staggering. (And I now have a lot better understanding of what the attendings and chiefs have been complaining about when they discuss the difficulty of operating on obese patients. Even in a person who’s only moderately obese, the weight and depth involved in abdominal surgery, and the strength needed to work against it, is significant and exhausting, and the visualization is frustratingly poor.)

But everything comes with practice, right? And what triumph when I found the right plane, when the anastomosis went together, when the skin was closed, when the patient woke up (and was still alive a week later, proving that the textbooks don’t have the final say).

A call-night story:

Sometime after the third unsuccessful code, and after walking the intern through a line in the ICU while we were both being paged by four or five separate nurses for patients with increasing abdominal pain/no urine output/difficult to arouse/heart rate of 150, we were admitting another patient in the ER, when the ER radios started chattering, and then people started walking up to me (the charge nurse, some ER residents, the tech who’s best at getting ivs on hypotensive patients): “Alice, did you hear yet? We’re getting a ruptured AAA. It was exciting the last time we did this together, huh? We’ll make sure to give you a heads up when the helicopter gets closer.”

The intern was also excited at the prospect. I used to be excited. By now, though, ruptured AAAs are no longer new and thrilling, they’re old and stressful. I would be just as happy not to be the point person for coordinating the response, and finding out if I can move things fast enough to save a person’s life. (I am still looking forward to actually being the lead resident on my first open AAA; probably that won’t be as great as I expect, either.) Called the OR, called the ICU, made sure that the ER had already told my attending what was happening. Then I ran upstairs to swing through the ICUs quickly, check on my hypoxic vent patients (solved by turning everyone’s PEEP up), and warn the nurses to ask quickly if they needed anything, because we would be unavailable for a while.

Back in the ER, five minutes ahead of the helicopter; the charge nurse came up to me again. She’s not usually very cheerful, but I think there was a lot of adrenaline going around, and she was almost smiling. “Alice, I just want to let you know, we brought a patient back with a cold leg. The ER staff haven’t seen her yet, but I thought you would like to know. She’s in room 10.” I had time for one quick look at the cold leg, which wasn’t too impressive. The patient was a frequent flier on the medical services, and vascular surgery had often been consulted for her legs, but never felt moved to intervene. I decided it wasn’t worth spending time on right then.

The AAA patient arrived: intubated, unresponsive, pale, unable to get a pressure, everyone in the room frantically feeling for pulses, unable to decide if we actually felt them or not. No time to waste. “Don’t worry about monitors or blood draws or better access – let’s get up to the OR and sort it out there.” We ran (as fast as you can when you have to wait for an elevator), and soon arrived in the OR. Anesthesia was not completely thrilled with our plan, which was to move the patient on to the table, scrub while they started inhalational agents, and then let them figure out iv access (only one or two peripheral ivs so far) and blood pressure monitoring (none so far) while the attending and chief resident started cutting. The anesthesia staff were good, though; by the time the surgeons were down to fascia, the patient had a central line and an a-line started.

I left an intern to scrub in and help retract (remembering how thrilled I’d been to have that job once), added his pager to my collection, and went back to look at the cold leg. Now 45 minutes later, it was clearly cold and pale. But given the patient’s complicated medical history, and the number of times I’d been consulted for a cold leg (on this particular patient) which turned out to be a non-issue, and given what was happening in the OR, I couldn’t recommend immediate surgery. So I called the radiology resident: “This patient has a cold leg. You could probably do thrombolytics, and in any case you could give us a definite diagnosis of where the obstruction is. Get your attending to come in, right now. My attending wants this done. He’s scrubbed in a ruptured AAA, don’t make me interrupt him to tell your attending to come in.” (Radiology and vascular surgery have a semi-complimentary, semi-adversarial relationship at my hospital. Friendly during daylight, but if you want a procedure at night, you have to dig in your heels and scream bloody murder. Sometimes it does come down to the vascular attending calling radiology and throwing his weight around.)

They came in, and it was a good thing they did, as the angiogram showed a lesion I hadn’t entirely expected. It still required surgery, but by then the AAA was stabilized, and the attending could pay attention, and started a second room.

Not a big deal, really, but I took great pleasure in treating that cold leg all on my own, without talking to the chief or attending till it was all settled; and a little perverse pleasure in taking my attending’s name in vain to get the necessary procedures done.

At the end of the day, all the patients and all their legs were still alive, which was a little astonishing. The only people who seemed to be in danger of collapsing were the vascular attending and chief resident, who had been operating for nearly 24 hours straight, and still had no end of their duties in sight. I don’t know whether to be excited or scared that I’m little more than a year away from that role.

One of the more unsettling experiences of my surgical career to date; and I didn’t think it could get any worse than stumbling through an erroneous CT scan reading during M&M:

I was doing a laparoscopic case (which is enough of an oddity in itself: the number of cases I’m getting this week would be going to my head, if I weren’t so overwhelmed with work outside of the OR that even these longed-for operations seem like a burden). First, one of the most senior attendings in the program wandered in, before we were even prepping, and started quizzing me about what was wrong with the patient, and why I thought so.

Then, after we got started, yet another attending came in; so I had three attendings watching me struggle through a laparoscopic case I had never done before. Of course they had a few helpful pieces of advice each, as well as the attending who was actually scrubbed on the case. Helpful comments like, Why don’t you just flip that piece of bowel over there, you would see so much better; go on, flip it over. (Yes, sir, I would be perfectly happy to, but I can’t seem to make the grasper go there. . . ) Almost more disturbing than them commenting, however, was them just watching. I couldn’t figure out what they found so fascinating. The case itself I didn’t think was that remarkable. It was new to me, but by no means new to the annals of surgery. And they certainly weren’t watching for the pleasure of admiring smooth technique. I thought it was painfully slow going, and I was the one doing it, which means it must have seemed glacially slow and awkward to everyone else. I got the impression they were waiting to see when I was going to tear the bowel. . . I almost respect their restraint in not saying so out loud. . .

On the other hand, that gave it a particularly triumphant feeling when I finally had all the pieces straightened out, and the problem was fixed, and I had done it nearly all myself.

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.)

I was scrubbed in today for a while, and witnessed the most violent outburst of anger I’ve seen in four years spent around some pretty volatile men. (I say witnessed, because as far as I can tell I wasn’t too close to the center of the target; I’m not sure how much he blames me, but we’ll see about that tomorrow.) My first reaction, besides shock at the amount of cursing, was, “how did he ever get this way? I can’t imagine ever getting to the point of being this angry, or expressing it so openly.”

And then I realized that I’m probably a lot closer to that attending than I would like to think. For instance, the other morning, I had to do several procedures with a nurse who probably qualifies as my least favorite ever. There are some nurses I dislike because I don’t think I can trust their medical advice (ie, they’ll say, “Dr. X would always start z medication now,” whereas in fact Dr. X hates that medication, and anyway it’s not at all indicated at the time); there are others whose opinion I might trust, but I dislike the fact that they are never available to help with problems in their rooms or their neighbors’. This particular nurse qualifies on many levels.

The harder I tried to get all the pieces lined up to get the procedures done in her room, the more ways she seemed to come up with ways to frustrate my efforts (I will allow that she was probably doing this unconsciously, in a sincere attempt to take good care of the patient; nevertheless it added up to thwarting all of my attempts to work efficiently). Finally, I was so angry and tense I would have been happy to throw some trash on the floor, except I knew that would bring our conflict way out in the open, and put an end to any forward momentum at all. As it was, I doubted that I would be able to do the procedure safely, I was so upset.

That morning, I got past it with a few prayers, and some meditations on the insignificance of these procedures to the course of the day, and how it didn’t really matter if I spent an extra fifteen minutes doing them safely.

But I can easily see how, if I had the power to throw things and yell without fear of retribution, and if the procedure I was doing was far more weighty and vital, I might well have chosen that as a method of venting stress, reasoning that it would be better to get it out so I could go on to concentrate on the procedure, rather than trying to keep it politely in, and be so tense that I couldn’t control my hands properly. I can even see how enough of these experiences as a resident, controlling anger, and then watching my role models express it, could make me happy to do the same when I reach that level. (This deliberate choice of a method of stress relief, to get back to the job at hand, would also explain the curiously swift changes of mood of most surgery attendings: they get very angry, then they calm down, and are back to joking and friendly. A few of them don’t let go, and they’re the really scary ones.)

I hope not. I know Paul said “be ye angry, and sin not,” and I’ve got to think that throwing things in the OR, even if only at the floor and not at people, probably counts as sinning while being angry. (Irony there, folks. I know quite well that it’s wrong. Don’t want you to get too concerned about me.)

I got to do a kidney transplant the other day. It was great. For one thing, the attending didn’t even draw a line for the incision. He just stood there, so I started measuring out for myself (two fingerbreadths above the inguinal ligament, which is a straight line between the pubic symphisis and the anterior superior iliac crest). He pointed a little higher (my fingers being a little small for the standard measurements), and then I just made the incision by myself. A small thing, I know, but a step away from the dotted line. . .

The best part was, when we got to sewing the anastomoses, he said, “You’ve been hanging out with the vascular surgeons, haven’t you? It shows.” And here I thought I hadn’t gotten enough OR time with vascular surgery to learn much of anything. It was good to have reassurance that I really have learned something since the beginning of this year (when I was on transplant).

High time to have learned something, I guess. Two weeks till the interns come, till we accept the current interns as our equals, till I’m a third year and have really no more excuses for not knowing the right answers.

Finally, I got enough vascular surgery in one day to satisfy my ambitions.

One of the vascular attendings is renowned amond the residents for his painstaking approached. He stops to look at the vein every few minutes while harvesting it, ties off things that may or may not be branches (as opposed to just tying off things which definitely seem to be branches; his approach takes more time), thinks for a long time about the path of his graft, and stops to assess the anastomosis several times while sewing it to make sure it isn’t kinking. He has been known to finish a 3 or 4 hour case, look at the anastomosis, and then take the whole thing down and start over because of a miniscule kink. In other words, he’s a perfectionist among vascular surgeons, who are perfectionists to start with. Also, he has a penchant for trying things that everyone else has given up on: dialysis access on a patient whose arms are covered with scars from failed fistulas and grafts; lower extremity bypasses on patients with 2mm veins for conduit (right on the margin of being too small to try), or whose only target vessel is a dorsalis pedis (so far down the leg that the vessel is tiny, and the utility is unpredictable; but they’ll lose the leg for sure if you don’t try). Thus, many people are happy not to get into the OR with him, knowing they’ll spend the whole day getting frustrated, and end up stuck late into the night, by the time he finishes his long OR list of difficult cases.

Which is a brilliant opportunity for the junior resident. The chief has gone off to do a glamorous great vessel reconstructive bypass (eg carotid-subclavian) with the attending who believes that speed is an essential factor for success in vacular surgery, and I’m left to do the entire day’s worth of cases with this first attending. It was great. Sure, he stopped every few minutes to think about the vein we were freeing up, and constantly expressed concern that I was about to cut a blood vessel (which was only what I was thinking to myself the whole time), but he let me do essentially all the dissection, and let me sew the entire anastomosis, no matter how slowly I went, or how maddeningly awkward I was with the 7-0 suture and Rankin needledrivers (7-0 suture is nearly invisible to the naked eye, and the needledrivers used for it are very delicate, and designed to let go of the needle so you don’t tear the vessel with it, making it difficult to hold onto the needle enough to make it go where you want before it lets go).

As we dissected out the veins to use for an AV fistula (for dialysis), or even worse, the artery to attach to, I kept misjudging the tissue, and cutting across a tiny branch before tying it off. This isn’t really the end of the world, but it gets blood all over the field, making it even more difficult to tell tissues apart, and it necessitates several minutes spent hunting down the two ends of the vessel and tying them off. Every time we had to stop and clean up, I was sure he would take over. But every time, he handed me back and the scissors, and let me keep going (which was almost more difficult; after a couple such failures, I would almost rather have had him take over and do it neatly, rather than force me to keep struggling; but it was much better learning). I certainly felt better when, in a few heavily scarred or complex areas, he did take over, and also got into bleeding that we had to hunt down.

At any rate, three such cases took us till 5pm. There was one “quick” debridement case on after that, but we were late enough to get caught in the switch of OR staff: the day people, who hurry a little bit in order to get done by the end of their shift so they can leave on time, were replaced by the night duty folks, who took the approach that they were going to be here till midnight no matter what happened, so if it took an hour to get our last case started, it didn’t really matter to them. I try to help and hurry things up, but there’s a limit to the number of times you can say “maybe we’re ready now?” before people get tired of you. Then, it turned out that the debridement was necessary because there was several inches of infected graft needing to be taken out, and the case lasted a few hours, and ended up requiring dissection into all kinds of places other than the one originally advertised. I was still pleased with myself. The attending let me do most of the dissection, even in an infected, scarred field where we were very unsure of the anatomy (as opposed to a untouched field, where you expect the arteries and veins to be in known locations).

So what, I didn’t get home till 9pm. That’s par for the course with this attending, and I had gotten to operate all day straight. The loupes were even starting to feel natural by the end of the day. Too bad that this attending books such full days only occasionally.

I’ve been trying to get used to using loupes this month, and it’s a catch-22.

Loupes are magnifying glasses used in vascular surgery and other delicate operations. Imagine a jeweler’s magnifier, but for both eyes, fixed onto a regular pair of glasses, designed to focus on objects 18-22 inches away from your face. If you usually use glasses, the regular glasses can be prescription strength; otherwise, plain glass. I forget the exact magnification, but it makes plain the front and back walls of vessels which would otherwise be hard to see; nerves jump out as different in texture from the surrounding tissue; 7-0 prolene suture, otherwise invisible, looks quite solid. They’re made individually, and cost an incredible amount of money; the only way I could afford them was by using the educational allowance.

The trick is that you can only see an area about 6 inches in diameter at this magnification. Everything outside that range is invisible. You can tilt your head, as though using bifocals, to look over the magnification, through the regular glasses part, but then you’re disoriented as to where things are compared to what you were seeing in magnification. The effort of focusing at such high magnification makes you feel a little seasick after a few minutes, let alone if you make the mistake of switching too often between the two views. (Which is why the techs have to hand instruments right into your hand; it’s really impossible to keep working if you have to look up to find the sutures and the instruments.)

Hand movements are difficult, too. I hadn’t realized what a component visual feedback is in the handiwork of surgery. I still have to be able to see at least part of the suture in order to tie correctly. I have to be able to see the needle to load it on the needle-driver. In the magnified field, it takes less force to move anything; your hand has less space to cross to get anywhere, so even a simple movement like suctioning is dangerous, since if you miscalculate the force to use, you could damage the blood vessel. And if suctioning is suddenly so complex, knot-tying is hopeless. I look like a complete klutz, just when I had finally progressed to the point of tying fairly easily, when not blinded by loupes.

Plus, the things are heavy, and to keep them from falling off your face into the sterile field, you have to tie them onto your head so tightly that I start to get a headache within minutes. By the end of the case, I’m so irritated I nearly trip over the cords and the nurses in my eagerness to get them off my head.

Most of the attendings and chief residents wear them for all but the most minor cases, because they do show tissue planes and small vessels with amazing clarity. Now that I’m using them, I can see how the seniors are able to dissect between structures where, with plain glasses, I could hardly perceive that there were two separate structures. Now, by the end of my second year, the attendings are asking questions if I’m not wearing them; they can tell if I can’t see the details they can.

It’s quite clear that I’m not going to be a vascular surgeon at this rate; but I still need to learn how to use the loupes, and how to do some vascular surgery. But it’s a catch-22: if I don’t operate with the loupes, I’ll never get any better; but I’m so hopelessly uncoordinated with them on that I can’t even pretend that it’s a good idea for the patient or the attending to have me around. (I have tried practicing on my embroidery at home, but that’s so flat, and the pieces so large compared to blood vessels, that it doesn’t seem to help.) I guess the only solution is to wear them for every single case I get into, vascular or not, whether they seem necessary or not, till I get more comfortable with them.

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