in the OR

Some friends at church asked me what my favorite kind of surgery was. This blog has given me the bad habit of being frank about my job, so I said, “Vascular surgery, because if you miss a stitch, blood shoots up at the ceiling.” They were rather horrified, and began relating how they had been traumatized by dissecting fetal pigs in high school or college. 

Note to self: There is a reason that most doctors never talk about their profession outside the hospital or clinic. From here on, even if people ask pointed questions and seem to be genuinely interested, I will say nothing. I will be a monument of discretion (yeah, right).

Which brings me to my least favorite part, at least of transplant surgery: dissecting out the external iliac artery and vein using electrocautery. This works out to the attending surgeon isolating pieces of tissue which he thinks do not contain any tiny blood vessel branches, and then me bovieing through them. So I’m holding one end of a 9″ long bovie, manipulating the other end deep in a hole, 1mm away from two very large blood vessels. This strikes me as an extremely bad idea. I still don’t know 1) how I get up the nerve to do it every time 2) how come I’ve never hit the wrong thing yet. But I guess that’s the whole point of surgery: cutting small things, surrounded by larger objects which it would be dangerous to cut; if you don’t get comfortable with that, the operation takes twice as long as necessary, to the danger of the patient and the annoyance of everyone else in the room.

The other option is perhaps safer, but not easier for me: right-angle clamp around a tiny vascular branch, pass two silk ties around it, tie off on both sides, and then cut in the middle. Which works out to 1) only 1 out of 5 scrub techs ever seems to grasp the concept of handing ties in a way that is of any use to the surgeon who only has one hand free for it; the attending doesn’t see the antics they’re getting up to, and not-quite-silently blames me for not completing the maneuver faster  2) the attending gets to critique my handling of the ties, and then my method of tying, over and over and over again. Which means I learn a lot, sure. . .

For the first time, I was the one called in in the middle of the night for a case. On one hand, it threw off my schedule a lot more than I’d expected. I’ve always told myself that getting up at night would be ok, because there’s such an adrenalin rush in the OR that I would wake up and be fine. We were partway through the case before I felt anything like that. I guess the excitement was more associated with novelty than I realized, and now that scrubbing on a case as the primary resident is becoming more routine, I can’t count on that energy for the middle of the night.

On the other hand, I feel like more of a surgeon than I ever have before, and it’s wonderful. A lot of it is due to the great attending I’ve been working with. He lets the resident, even as junior as me, have the surgeon’s side of the table, and make a lot of small decisions about how to proceed next. He doesn’t criticize the whole time, which makes it so much easier to work; I know he’ll only say something when he really means it. He makes me really a part of the case – dissecting difficult spots, making some decisions about sizing the vascular anastomoses, sewing the anastomoses, and tying important knots in deep corners. (The ones that I have too much of a tendency to break. . . but not last night.) I think I’m actually becoming slightly competent at some of this; not quite second nature yet, but it will be soon. I can start to think about the whole course of the operation, and the strategy, rather than having to concentrate completely on just how to hold my hand next.

So what if the price is losing a night’s sleep. . . it’s worth it.

It seems like my dry spell is at an end, and I’m starting to have my hands full of transplants.

Which leads to another topic: The only thing that surgery residents love more than gossiping about each other is critiquing the attendings. I’m not really into that. (Or maybe refighting the dramatic cases; that might be the top pastime.)

I learned to do calculus and chemistry and anatomy and biochem by not questioning the teacher’s assumptions. I know that doesn’t sound scientific, but I used to ask “why?” or “how do we know that?” so much that I could never get to the main point of the lesson. So I stopped. I tried to jump into the subject: assume that all the axioms the teacher grants are correct, let’s see how it works.

Same thing with surgery attendings. I could go on and on about the trauma attendings, because I didn’t operate with them. But now that I’m operating with attendings on a semi-regular basis, I try not to analyze their personalities too much. They are far better surgeons than I am, and they’re trying to teach me something. Complaining about not fair this or not fair that is not going to help with the goal. If I concentrate on doing what they want me to be doing with my hands, eventually I’ll get beyond the words they’re using. I’m frustrated with myself when I don’t do it right; I can only imagine how frustrating it must be for someone who could absolutely do it right the first time himself to keep his hands off and let me try again. So I don’t care how harsh or edgy things get in the OR, as long as the attending is teaching.

Which further establishes my reputation among the rest of the residents as naive, because no matter which attending they’re discussing, my answer is, “I didn’t think he was so bad. We get along ok.”

One of the attendings, explaining his decision to hire a female partner, remarked, “Women make better surgeons, honestly. They have more natural dexterity.”

All the women in the room waited for the inevitable other half of the comment.

After a pause, he continued, “The only thing is, they can’t concentrate. Guys, when they’re doing something, think only about that one thing. Women, their minds are all over the place. When we operate, we’re not thinking about the laundry that needs to be done, what we’re going to have for dinner, what to do with our hair, and so on.” Laughs all around.

So I’ve been trying to analyze ever since my concentration in the OR – which of course is impossible. My conclusion is, that I do multitask all the time. Dinner figures in, but there’s also which patients need to be checked on before I leave, which labs need to be reordered for the morning, which consultants I need to talk to. On the other hand, I do think that when we get down real surgery – actually cutting and sewing, not just looking at things (and especially me not just retracting and daydreaming) – I don’t think about much else. I do continue to notice what anesthesia is doing, and what the vital signs are, which I guess the men don’t. Most of the attendings don’t know what anesthesia is doing unless the CRNA or I tell them, and they do seem to get upset by any evidence that I’m looking at anything in the room besides the operating field. (I know, you’re not supposed to take your eyes off the instruments, or you could lose the structures.)

Comments or further observations?

Finally, some action. Went on a donor run with an attending I haven’t worked much with before.

My main conclusion from this is, that the popular conception of surgeon’s hands as delicate is quite wrong.

The attending handed me about eight liters of ice to break up (to pack into the abdominal cavity to cool the organs after cross-clamping), and instead of, like other transplant surgeons I’ve worked with, growling in frustration after watching me for five seconds and taking over, left me to finish the job by myself. Which was salutary, but painful. Between the ice and the hammer, and then tying knots in nylon afterwards, my hands are all scraped up, and my arm is going to be sore for days. I need to take up weightlifting.

The surgeon not knowing me was also nice because he assumed that anyone sent would be familiar with the proceedings, and let me actually cut a lot of things. Since he kept talking as though I was a senior resident (I did explain, eventually), presumably I didn’t do too bad of a job. Real surgery, finally. Now I just need to work on the sewing-up-after-cutting part.

Another thing I need to learn to be a real surgeon: When doing an open abdominal case on a patient who’s had practically any previous operations, there are bound to be adhesions to some extent (unless they’re on chronic steroids, in which case you get the prednisone effect – wonderfully smooth going in, and the near-certainty that they won’t heal afterwards). Depending on how many surgeries and where, and the patient’s genetic tendency toward scarring, there will be more or less adhesions, and it will be more or less difficult to get where you’re going.

When dissecting the adhesions apart in order to get to the underlying structures, you have to protect the bowel somehow. Touching the intestines with the bovie (electrocautery) is very much frowned upon, and can lead to all kinds of complications, ranging from post-op abscesses to enterocutaneous fistulas.

There’s a really simple maneuver to help avoid this. You slip your gloved finger under the band of adhesions, separating it from the bowel underneath. Then you bovie on your finger.

The bovie is hot.

This can really hurt.

If you don’t time it just right, you can go right through the glove into your finger.

The good surgeons 1) know how to time it, and 2) care more about protecting the patient than about how hot their fingers get.

I am still a source of frustration to my mentors for two reasons: If I ever have to put my hand under the bovie, I can’t take the heat, and I back off way too soon, which makes it take forever to get anything done (which is too bad, because it’s quite a privilege to be given the responsibility of putting your hand under and guiding where the incisions will be made, and I hate to mess up when an attending lets me do that). Or, when it’s their hand in there, I hit it. Either way, not popular.

I need to do some more surgeries.

Sorry folks, nothing useful to say. I’m going through another disillusioned-and-bitter phase; judging by precedent, it shouldn’t last more than a few days. Will return with regular programming then.

(The funny thing is that, even though I feel depressed and bitter and cynical, I’m still known for being cheerful and optimistic. The chiefs are still telling me, “Wait a few years and see if you’re still so happy about everything.” I feel like I’ve turned into all the cynical surgery residents I knew as a medical student, but apparently it doesn’t come across that way – yet. I guess that concluding every consideration of a patient’s worsening symptoms and grim vital signs with the hope that they could still turn around in the next two days has to count as incurably optimistic; and persisting in treating people who complain of pain seriously has to qualify as insanely credulous.)

(Although if they could hear my interior monologue when answering pages, they might understand better. I had another several of my favorites today, calls where the nurse goes on for several minutes, telling you normal vital signs and urine outputs and stating that the patient has taken all their medications as directed, and you keep waiting for some kind of punchline – what’s wrong enough to be worth calling me about? – and there never is a punchline, and you’re left to say as politely as possible, “Thanks for telling me.” Or my other kind of favorite, the one that invariably happens right after I scrub in, while I’m supposed to be prepping and draping, and the circulating nurse kindly answers the page, listens with a widening mouth, and then says tentatively, “Your patient in ICU room three has a pressure of – let me check – 62 over 30, is there anything you would like them to do?” Um, find me a time machine so I can be in two places at once. And the attending cheerfully motions to me to finish draping, remarking that this is one of the purposes of training, to learn how to juggle multiple serious responsibilities at once. Thanks sir, that really helps.) (The patient did very well in the end. I never calculated pressor doses that fast before.)

It was a Saturday night, and I was on the vascular service, so being on call meant I was covering the vascular patients, plus urology, plus plastics. Which can add up to a lot, if the urology attendings have decided to do a couple of radical prostatectemies and urological reconstructions before leaving for the weekend. Or if plastics is on call for traumatic injuries. Fortunately, urology was quiet, and plastics was only on for hand injuries, of which there were none.

So when, around midnight, five or six ATV accidents started coming in in short order, I had time to go help. I had one end of the trauma bay, and I got the third helicopter transport, a young man, fairly alert, with some scalp lacerations, lots of bruises and lacerations everywhere else, and a mangled left leg. ATLS protocol, by the book, didn’t show much of anything – except for that leg. The foot was hanging at a strange ankle, and the foot looked quite pale compared to the other side. No pulses were palpable and he could only wiggle the toes.

The orthopedic resident was moving from one stretcher to another, distributing splints, and making notes for who would get to go to the OR first. He cocked his head at this one. “I’m not getting any pulses here, perhaps you guys should consult vascular.” “It’s ok, I am vascular,” I told him. I had already dug up the hand-held doppler, which is the mainstay of vascular workup in the ER: if you can hear pulses, it’s not too bad; if you can neither feel nor hear the pulses, then the limb is truly ischemic and will be dead within a couple of hours (6 is usually quoted).

The trauma attending finally had time to get to that end of the bay. “This is a pretty bad open fracture. Can anyone feel pulses? Maybe we should consult vascular surgery.” “Yes sir, I am vascular; I was just helping out down here. I think it’s bad, there are no dopplerable pulses, and we’re about to call our attending.”

The situation was fairly textbook: an open fracture with clear distal ischemia. Don’t pass go, don’t collect $200 or any further studies, proceed straight to the OR. Since I had nothing better to do except sleep, I helped move the patient into the OR, and watched the orthopods fit the pieces back together and fasten them in place with an ex-fix (external fixator; like lego outside the leg; it stabilizes fractures, especially contaminated ones, for a couple of days, usually in preparation for definitive internal fixation; they’re cumbersome, and people often try to ignore their presence, but it’s actually easier for the patient if you move the leg by holding the ex-fix, since that won’t make the broken bones rub against each other, which is what really hurts).

Then, since my pager kindly remained silent, I got to help the vascular attending and chief (one of my heroes: smart, and good to work with), who were by this time fairly beat, since it was the fifth emergency case of the weekend. We prepped both legs, and the chief and I harvested the saphenous vein from the uninjured leg through a series of small incisions that we tunneled between to reach the whole vein, while the attending cleaned up around the injury on the other side, and found healthy artery on both sides for the anastomosis. He and the chief each took one end, and attached the saphenous vein to the healthy artery, while I started closing all the incisions on the other side. Ortho had already made the fasciotomies (long ugly slashes through the fascial covering of the four muscle compartments in the calf, necessary to relieve pressure and prevent ischemia after a serious injury or period of ischemia), so all we had to do on the injured side was wrap yards of kerlex and gauze around the entire structure of the ex-fix and our incisions, and we were done.

The poor vascular team still had two more cases to go, and I had to go attend to some urology patients about whom I had received no signout. It made for an incredibly long call day, but that was my favorite night to date: a dramatic, classical injury, which I got to follow from the door through the OR, and then round on for the next few days. Talk about continuity.

I love hernias. Repairing an inguinal hernia seems to be an activity most akin to juggling several balls while standing on your head facing backwards. In other words, after doing it a couple of times, and reading three different textbooks prior to the most recent effort, I still have only a minimal understanding of which piece went where and why.

There are four or five main layers to the abdominal wall, I get that much: skin, fat, Camper’s fascia, Scarpa’s fascia; then you get the external oblique muscle – but down that far, there’s only the external oblique aponeurosis, which runs into everything else; and the internal oblique, and its aponeurosis; and the transversus abdominis, which blends into stuff, and the transversalis fascia; plus the preperitoneal space/fat, and the peritoneum itself. Now if all that would just lie flat, it would be enough trouble. But then it bends, apparently through a warp in the space-time continuum, and you get the inguinal ligament, Cooper’s ligament, the external inguinal ring, the internal inguinal ring (if only I had One ring to bind them all!), and the cremaster fascia. I keep reading the textbooks, and turning them around and around trying to figure out what Cooper’s ligament is and how it relates to all the rest of this stuff, and I still can’t see it. As a sign of how lost I am, when they illustrate this anatomy unilaterally, they usually don’t label left/right, up/down, and I can’t even tell where we’re at, or whether we’re looking from the inside out, or the outside in, let alone where things connect to.

So it’s a good thing I’ve been doing this with one of the quiet attendings. He doesn’t say much of anything unless you’re recklessly out of place (for instance, being so awe-struck by the sight of the hernia suddenly dropping back through the hole – a hole, any hole - actually the internal ring - back into the peritoneal cavity, that you completely forget how to tie knots, and start tying them a couple inches into the air, when he mildly observes that maintaining tension on the suture tends to make for a tighter knot, and thus a more durable repair). (That was last time, this time I got a grip on myself, and the suture, too.) Anyway, although I have no doubt that I’m making all kinds of wild gestures through my lack of comprehension of where we are or what we’re going to do next, he hasn’t said anything, at least to me.

I feel like this is fascinating enough to keep doing straight for a couple of months at least; maybe by then I’d figure out which way is in and which way is out.

(In other news, when the ICU nurse warned me that the critical care attending was doing things with my patient, and likely to go farther, I tracked him down, and remarked in a polite manner that I’d been talking to the patient’s family. He informed me in a rather high-handed tone of his intentions to completely manage my patient in the future. I said no, now that he mentioned it, the patient was on my attending’s service, and the surgical team felt quite comfortable taking care of the foreseeable future. He did a double take, and I stuck my chin out and said we could handle it quite nicely, thank you. It felt good to get that out in the open, and certainly he hasn’t been seen or heard from since. Unfortunately it didn’t improve my patient at all. I wish I could ward off the angel of death as easily as that.)

Not much going on these days. The medical students are fun. They’re so incredibly young and naive and eager to please. It’s a great responsibility, to feel that we’re responsible for their first experience of clinical medicine, their first understanding of how to deal with real patients and function as part of a real team. I’m afraid we’re rather a dysfunctional bunch, this month, and I hope it doesn’t teach them too badly.

I’m not happy about the case distribution, but I’m telling myself that all the cases belong to the chief, absolutely; if he decides to let me do any, it’s a gift, not a desert. I knew that last year, because I made myself have no expectation of doing any cases at all; then I was purely grateful if the chief threw me one. I need to hold on to the same attitude this year: if the chief lets me operate, it’s a gift. I wish it weren’t that way, but that’s how the chief sees it, so I’d better fall in line.

It’s actually still a little funny to me, how little say the attendings have, openly, about which resident comes to which of their cases. They make general rules – no interns or second years in cases of a certain complexity – but beyond that, they don’t say anything, even about the residents they like the least. The chiefs control who goes where, even to the point that some chiefs can send junior residents into big cases if they want to. My chief this month is not the kind to do that; he’ll go recruiting residents way beyond our service to cover cases, if he thinks the case is too big for me, and he won’t let me operate at all unless we have two rooms running constantly. I don’t appreciate that, but it’s July, and I’m sure in a year or two I’ll be horrified to see young second years doing anything like good cases.

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