in the OR

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.

As usual whenever I slip into sharing details about my surgical activities, this story is probably going to scare some of you. It shouldn’t. Whatever my dramatized retelling sounds like, I’m responsible enough, and my attendings know it, to ask for help when I really need it.

I’ve been working like crazy for the last few weeks, and once again getting very frustrated about not being in the OR, especially when I felt that some cases were really fairly “mine.” Of course, there’s no such thing as fairness, or deserved, when it comes to cases for junior residents. The cases belong to the chief. Just because the chief can’t physically make it to every single one doesn’t change the fact that they belong to him, and it’s his right to assign them however he wants. If he wants to give them to senior residents on another service rather than a second-year on his own service, that’s his right. That’s the way surgery residency works. Or so I was reminding myself through gritted teeth. Maybe I wasn’t completely silent on the subject.

Anyway, as I was between two admissions, the chief paged me: “We’ve just added another complex revision on to the afternoon schedule. Why don’t you come transport this last patient to ICU, and do the next case, so I can eat lunch, before the add-on?” I ran down the stairs to oversee transporting the patient (with five tubes and drains, and six monitors beeping the whole time) up five floors and across half the hospital, then finished the admission orders while the next patient was being gotten ready.

Basically, we needed controlled arterial access on both sides. After draping, the attending waved me over to the other side of the table. He checked the landmarks, and drew a line. “Ok, get down to the artery so we can put loops around it.” And he started cutting down on his side.

I stared at the inked line, and nearly missed the tech impatiently trying to hand me a scalpel. Get down to the artery, indeed. I knew that this was a very basic maneuver in vascular surgery and particularly in this procedure, and I knew the senior residents did it all the time, and regarded it as simple. But I’d never seen it done from start to finish. The line seemed like a good place to start. I made the incision, and started in with the bovie, all the while thinking, “the artery is in here; I have to get the artery out, and I have to keep it in one piece; if I bovie the artery, or the vein, they’ll never let me operate on vascular surgery again.”

The attending meanwhile was flying along on his side, one instrument after another. His hole was now quite deep, and he was so far ahead that I couldn’t even look at what instruments he was using for guidance. The tech, meanwhile, kept trying to hand me the instruments he thought I was supposed to be using, but I was going so slowly that they were always the wrong ones.

I came to what looked like a large vein, and made some vague noise to the attending. He glanced over. “Oh, that’s just a varicose vein. Go ahead and ligate it.” I didn’t know you could have varicose veins there; so I ligated it, and went on. The next several such veins I recognized on my own. As I got deeper, though, I got slower. I could not remember what exactly the other surgeons did to not hit the artery. I was not used to being completely on my own. Eventually, the attending finished his side, reached over to mine, and in about three movements exposed the artery, safely covered with a fibrous sheath. The right way to do it, it turns out, is to simply bovie down till you come to the sheath, which there isn’t much chance of going through accidentally.

So there was really no danger the whole time. For all that I hated not being sure what I was doing, it was the most amazing fun, proceeding along on my own, without the attending’s hands in with mine, responsible to find things for myself. I want to do it again. . . Of course, since I made the mistake of blurting out to the chief resident what a thrill it had been to do that for the first time all on my own, he may not let me in such a setting again. . . I may be optimistically mistaken, but I don’t think the attending knows it was the first time I had ever been into that anatomical location. Maybe he does. Either he thinks I’m hopelessly slow and cautious, or he knows it was the first time.

Take this in context: Another attending was relating tales of his days as a cardiac fellow, decades ago, when he never left the hospital all week, and by corollary, did entire bypasses and valve replacements on his own, with an intern assisting. My hours, and my adventures, are small fry to the days of the giants.

I’m making my way through Cameron’s Current Surgical Therapy, specifically the vascular section, since this is the kind of problem I am most worried about handling alone at night. For one thing, I have a terrible knack for imagining that I feel pedal pulses when there aren’t any, so I always have to make myself get the doppler and check (if the pulse is palpable, it necessarily ought to be audible with doppler; although sometimes, finding the doppler in the depths of the nurses’ station, or on another floor entirely, is almost more challenging than finding the pulses). For another thing, there are so many possible ways to treat vascular problems nowadays, and I feel inadequately versed in all the options, and which ones are appropriate in the middle of the night, and which ones are adequate in emergencies and which ones aren’t.

So I’ve gotten to the chapter on pseudoaneurysms, which touches on infected pseudoaneurysms of the femoral artery, and mentions that proximal control on these can be difficult. Which gives me flashbacks to vascular rotation last year, when I somehow found myself scrubbed with one of the most senior and demanding (but also rewarding) of the vascular surgeons. The case was supposed to be a simple oversew of a leaking femoral patch angioplasty. Half the subsequent bloodbath can fairly be blamed on the attending, for being so silly as to suppose that it would be that easy (as he acknowledged later, it was an ostrich-like plan; not that I made any objection at the time). The other half can fairly be blamed on me, for not yet being facile at controlling bleeding vessels with forceps or right angles to facilitate tying off, and for not being good at using the last two fingers as a third hand, in order to retract one thing and hold another at the same time (which faults he explained loudly, in between recommending anesthesia that if they hadn’t called for quantities of blood for transfusion yet, they’d better hurry; anesthesia, not having looked into the field or at our suction canisters, did not understand the urgency).

By the end of the case, a certain quantity of the patient’s blood volume was in those canisters, and another, smaller, portion was on me and the attending; and I had a much better grasp of the concept and significance of having proximal and distal control before trying to do anything to a blood vessel. These two pages of the textbook sound like a reminiscence about that case. . . The site turned out to be infected, and required one or two more operations to thoroughly correct the problem.

This month is flying by. I’m staying busy enough that I’m finally understanding the sensation of “not another case – it’s after noon!” The surgery center, with its motivated staff and fast turnover, is one thing, but in the main OR, things drag and drag, and even a short list of three cases can end up stretching out to the point that one single add-on seems an imposition. Not that I’m complaining; this is also now enough time spent continuously in the OR that I’m more comfortable with all kinds of small routines, even as small as making an incision (yes, ok, major failing for a would-be surgeon, but cutting on people takes a little determination to actually get into something, and not just scratch the surface).

Hernias, especially. I know I still need to do another hundred (literally) to really understand what’s happening. But in the past few weeks I’ve done enough, often enough, with the same attending, that I’m at least starting not to be surprised when certain structures show up in the same place over and over. Today, on an athletic young patient, I even recognized the conjoined tendon (in elderly patients this area where tendons run together can be so attenuated that the “conjoinedness” is more theoretical than actual). This is an important procedure for me, because if I plan to be a community general surgeon, this is going to be a major part of my practice. Right now I can’t quite picture sorting out all the different layers by myself; but we’ll get there.

Today was better. This whole month really is the best of the year so far, so I don’t know why I’m getting such a bad attitude as demonstrated yesterday. I have more responsibility and more OR time, and they’re thrilling. It’s the in-between parts that get me down.

The chief and I found ourselves diving into a complicated abdomen. The attending was there, but for some reason was content to let the chief and me keep working our way through. Perhaps he was disgruntled. Perhaps, more complimentary, he trusted the chief (which was warranted). I didn’t really care why; I was deeper in the abdomen than I’ve really been so far, and the chief was expecting me to pull my share of the work. (Our medical student was present, but was one of those persons who is clearly cut out for a life in internal medicine; unable to even handle scissors, but enthusiastic about certain other, worthy, areas of medical knowledge. He and the residents have basically settled on peaceful coexistence: we overlook his inability to master the most basic manual skills, and he listens politely as we engage in surgical shop-talk: discussing in details the pros and cons of different incisions to use when approaching a problem.)

Anyway, I’m fairly certain the chief didn’t appreciate my rediscovering-the-wheel approach to abdominal surgery, but he put up with it, and kept pushing me to do more. What can I say; it’s a sad state of affairs to be sure, but some basic things, like how to keep the small intestine out of the way while you’re trying to go somewhere else, were new to me. Usually the attending does it, because it takes so long when I try to do it. The cases I’ve done so far have been in corners of the abdomen (inguinal hernias, gallbladders, transplants to the iliac fossa) where the disorganized nature of the middle of the abdomen doesn’t usually come into play.

I hope the chief’s patience extends to letting me into the OR with him some more, because the only remedy is more practice. I admire this chief a great deal, for his operative skills, and for his ability to put up with my efforts at assisting in the OR or managing ICU patients; but I doubt whether he recognizes, or cares about, my admiration.

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