in the OR

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.

Back in the OR at my own hospital, I realized several other things I’d been subconsciously missing at the children’s hospital: besides a mutual recognition with the techs, nurses, and anesthesiologists, and material things like scrub sinks working the way they should, trash bins sitting where they should, and light handles that fit the way they should, I’d missed the attendings caring what I did. At the other hospital, I was very much a  migrant: they put up with me for six weeks, and now they’ll never see or hear of me again. As long as they kept me from doing any positive harm in that time, they could care less whether I learned to operate well. Here, the attendings know they’re stuck with me for several years, and I think even beyond that pragmatism they’re committed enough to teaching that they care about my learning.

This manifested itself in the attending criticizing nearly every move I made for two hours. The minute we started draping, it suddenly hit me that this was a much more complex operation than the appendectomies I’d been doing for the last several weeks, and I nearly froze. It took an effort to do simple things, things this attending long since expected me to do quickly and semi-smoothly. Him telling me to loosen up didn’t really help, but after ten or fifteen minutes I started to get in the swing of things. Back to the usual pattern of him stopping every five or ten minutes to explain why my actions were completely counterproductive, stupid, harmful, or simply inelegant.

That may sound like a complaint, but really it was good (and even better when done with) to have the attending take the time to talk about technique. This attending likes to repeat, “You should do every case as if the patient was your own mother.” Personally I find the metaphor a little disturbing, but he’s teaching professional attention to detail at all times.

At the end, I found that in the middle of all the stress and criticism, he was actually letting me do more than he ever had before – which was why he found so many things to teach about.

And that leads to a last humbling conclusion. I have so much more to learn about surgery before I will even begin to be a surgeon. Now I begin to get the hang of where an operation needs to go, what the next step needs to be; but on my own, I go so slowly, hunting and pecking my way through. I don’t have the confidence in my plan to jump in, and push, cut, tear, burn things to get where I’m going. And that’s what it is to operate: to know so thoroughly where you are, and what needs to be done, that you can cut without hesitating.

I feel sorry for the OR team that got stuck working the same night with me. We had a case of perforated appendicitis, the kind where you start regretting the decision to operate the minute pus starts oozing out of the first incision. (Note to ER doctors: unless the patient has a creatinine of 3 [indicating real renal failure] never ever ever do a CT scan without iv contrast (ok, unless you’re looking for kidney stones); and there is literally no excuse in the world for not giving oral contrast to a patient over the age of reason – appropriate use of antiemetics should enable the patient to get at least a modicum of the contrast down, and some is better than none. For the non-medical readers, iv contrast is invaluable for demarcating abscesses, which are characterized by a vascularized wall, and no blood flow inside. It also helps to diagnose dozens of other surgical conditions, including mesenteric ischemia, ischemic gut, and small bowel obstructions which need an urgent operation (as opposed to the ones that can wait). Oral contrast is necessary to show which round objects are intestine, and which could be something else, like an inflamed appendix or an abscess. Not having contrast is like trying to peel potatoes in the dark – a waste of time and radiation.) (Note to self: next time, when the patient has diffuse peritonitis on exam, you should ignore the worthless noncontrast CT scan which may or may not show an abscess, and go with your clinical diagnosis of a perforation that’s had time to spread.)

(Appendicitis complicated by perforation and an abscess ought to be treated nonoperatively, because surgery is too difficult and risky in that setting. Like many other medical pearls, I didn’t quite believe that one until I proved it for myself. Someday, I’ll stop reinventing the wheel.)

It’s not that I did the case badly, just very very slowly. I’m doing better at getting the laparoscopic instruments where I want them to go, but things take twice as long when I drop everything I pick up, and have to grab it again and again before I get a grasp that works. However, as the attending observed, since there was already pus everywhere, things could hardly get any worse. . .

Better luck the next night, I guess.

It’s a good thing I have to admit so many kids with appendicitis and non-appendicitis, because I need more work on laparoscopic appendectomies.

This became abundantly clear last night when, two-thirds of the way through a case, the attending commented, “Do they do laparoscopic appendectomies at your hospital?”

“Well, yes sir, they do, but I haven’t gotten to do any there yet.” [so the fact that I seem to have two left hands is really not my program's fault] 

The appendix being at the other hand of the abdomen from the stomach and gallbladder, which is what I’ve mostly worked on (or tried to) laparoscopically, appendectomies feel like working upside down and backwards – and it shows in my random sweeps which usually don’t even get my instrument onto the screen, let alone do anything helpful to peel back the inflamed tissue and expose the parts that we need to be working on.

Peds is good. The babies are cute. Actually, this is a problem on rounds, because I would rather play with the babies than pay attention to the details of calculating their feedings or TPN orders.

The anesthesia part is amazing. Anesthesia for these tiny babies is incredibly delicate. The ET tubes for the smallest babies are about the size of an adult venous introducer. . . And for the older children, the finesse with which the anesthesiologists talk them into staying calm during the trip back to the OR (admittedly, with the help of versed) is impressive. For adults, induction of anesthesia is usually performed with an iv agent – quick. For kids, though, they avoid putting in an iv until they already  have them asleep with an inhalational agent – which means they have to be bagged the whole time an iv is being found on their tiny hands or arms.

Not to mention the matter of waking up: In adults, you like to get some definite responses to commands before actually pulling the tube out. For kids, there’s no way they’re going to do anything coherent while still coming out of anesthesia, so the anesthesiologists have to just pick a moment when they think the child is awake enough, and doing some spontaneous respiration, to pull the tube out, and wait to see what happens. After all, they’re small, and easy to ventilate by hand if they need a few more minutes to wake up. (Some anesthesiologist will no doubt come by and explain that there’s a lot more detailed calculation involved. Either way, I’m impressed.)

The OR and ICU staff are coming to the conclusion that I’m crazy. They can’t tell why else I would spend the day with a stupid grin on my face, when all they can see is that I have some of the sickest patients in the ICU, the worst cases on the schedule, get no help with scutwork from the more senior residents (some seniors help, some don’t; mine don’t), and have attendings whose form of praise (I’ve decided) is to come up with more unique phrases to explain how incompetent I am. (I know this because he was doing it today while I was doing a simple job perfectly, so I think he really meant it was nice to have me around so he could say things like that.)

It seems a little embarassing to keep explaining to everyone I see that I’ve been doing more surgery in the last few weeks than ever before, and more complex. After all, it’s hard to admit even to the OR nurses that this is my first time at nearly all these procedures. I’m perfectly happy to have an OR schedule crowded with hard cases, because that means some good ones trickle down to me. I don’t mind staying late nearly every night, because it means I’ve been in the OR most of the day, and have to stay late to catch up on people.

The sick ICU patients are not so great, but at least they’re all still alive, which is more than we expected of some of them. And them being sick is not my fault, not by the remotest stretch of anyone’s imagination, so I can take care of them without feeling guilty for them being in the ICU. (As in, if I had paid more attention, would I have noticed some miniscule fact that would have made a difference in their care earlier.)

Posting has been a little light due to a recent transplant marathon: one transplant after another, starting in the afternoon, and concluding the next morning. The best summary would be to say, that after doing so many of one procedure in a row, I knew the steps in my sleep – which was good, because that was what it was close to by the end. . . I still wasn’t able to satisfy the attending, who seemed to want to know why, twelve hours after he’d first told me I needed to improve a point of technique, it still hadn’t been corrected. (Saying, Sorry, right now I’m lucky to be standing up straight, and doing something at least functional with the instruments, can’t think straight enough to change habits right now, did not seem like a good idea.) (I sent the poor medical student to bed some time after midnight; he also seemed to find that irrational, but neither of us had enough energy to discuss it in detail.)

I got my fill of “continuity of care:” admit one patient, scribble some pre-admission orders (stat labs and induction immunosuppression) for the next one, run down and do the back-table on one kidney, go meet and examine the second patient, do the first case, write pre-admission orders for the third, back-table the second kidney, go check that the first one is still making urine, look at his chest x-ray, and continue. . . Then, the day after, even though the attending and I rounded before leaving the hospital, so I technically had handed over coverage of my patients to an on-call intern, neither I nor the nurses felt like leaving the intern in charge. If I didn’t wake up every hour to call and check on someone, they were paging me, or else had stumped the intern and he was calling to ask me. . . Eventually I gave up on sleeping and tried to get some chores done instead. I hate that feeling of waking up, and not being able to remember which nurse I had intended to talk to this time, or whether the fluid bolus I’m thinking about is something that has already happened, or that I still need to order. I keep intending to take a paper with me and write notes, but around the time that the difference between am and pm disappears, the coordination required to get a paper and pen in the same place also drops off. The significance of low urine output, however, sticks around.

It’s taken me 16 months of residency to find out what surgery as a profession is really like. I need to figure out who in the hospital has coffee available at midnight before trying that one again. Otherwise, give it another day or two, and I’m up for it.

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