in the OR

I got to do my first transplant today.

More precisely, I assisted the attending for the first time today; but I have high hopes of getting to do more of the procedure later on. I really didn’t want to ask for anything more; I was still figuring out the anatomy (well, ok, so the external iliac artery and vein are not that complicated; but the way that the donor artery, vein, and ureter fit in is), and I don’t have much experience sewing blood vessels yet. So I’m content to wait through a couple more of these till he feels like letting me do some of the work.

The transplant attending, as I’ve mentioned before, is completely dedicated to his work, and is extremely hyper when there’s a transplant in the air. He haunts the OR, pacing back and forth, waiting for his room to be ready, calling the coordinators to check on the exact location of the organ in transit. He greets the patient, hugs them, asks if they’re all ready, or have any last-minute questions. He helps position the patient, helps anesthesia put the lines in (ok, so I’m not sure anesthesia wanted any help, but they got some), helps put the foley in, helps arrange the blankets, all the while commenting, “transplant means paying attention to details, Alice; you have to check on everything.”

Then we’re scrubbed in, and the noise level drops off. Everything has to be just so for him, but he has a reason for all of it, so I just do my best to adjust to the way he wants things. No extraneous movements. No unnecessary tension on anything, and above all on the donor tissues. Stay in the bloodless plane between tissue layers; watch the muscles split apart, the artery and vein separate off of each other. Tie countless knots onto nearly-invisible branches off the artery and vein, which will bleed all over the field after the anastomosis if we don’t get them now (“you’re tying better now than when we first met, Alice”). And then the nerve-wracking, painstaking business of matching the veins together, placing the stitches, sewing down; repeat for the artery. The ultimate test: “we’re about to take off the clamps, anesthesia, you all set? all the meds in? the pressure is good? here we go. . .” And the dead-white kidney turns in a split second to a beautiful pink, and you can feel the blood pulsing through if you just lay your finger against the capsule. Watch, and the urine comes dribbling out the ureter. Success! Then the last steps, catching all the little bleeding spots and sewing them shut, patching the ureter onto the bladder, tucking the whole thing into that artificial space at the edge of the pelvis, and watching as you close the muscles to make sure the pulse stays strong, nothing kinks.

I love the sewing and tying, the part where I got to help the most. When I read him right, and had the sutures ready to throw down the minute he had the right-angle clamp where he wanted it, it was beautiful, like a miniature dance. I can’t wait to do this some more, so I get better at predicting the next step, and can do more to smooth things along.

At last, everything closed, we got ready to move the patient off the OR table. The foley bag was already filling up with pale urine, the first that patient had made in years, and it was the most beautiful thing in the world. We changed that patient’s life. We, and the family who donated the kidney. (I didn’t ask how the donor died; I knew it was a young person, and I didn’t want to think about it.)

One of my patients this month has been an amazing teacher. He hasn’t said a word yet, and I might be off the service before we get him off the vent and onto a trach that he can talk with, but I’ve already learned a lot from him.

He was in a car accident, and came in with some broken ribs. Not bad, right? So no one could understand why his vital signs steadily dropped in the trauma bay. He looked good initially, but right when the team thought they had him figured out and ready for admission upstairs, he took a turn for the worse. The on-call attending stayed four hours late, intubating him, scanning him again, starting him on pressors, fighting with the vent settings, trying to save his life, and completely lost as to what the problem was.

He got to the trauma unit eventually, and I picked him up. We spent the next three days desperately trying to figure out what on earth could be wrong with him. He seemed to be septic – but how can you be septic from the moment you hit the door? That should be something that starts three or four days in, not that gets to its worst three days after admission.

Finally, the attending who had first admitted him came back on call. He came to get signout from another attending, and found us all kind of hanging around this patient’s room. He was by that point on three or four pressors, and extreme vent settings were barely keeping his oxygen level in the acceptable range. The attending looked at the situation quietly for a couple of minutes and then announced, “He’s clearly septic, and we have no idea why. It’s time to do surgery. I’m calling the OR.” The rest of us mostly shrugged our shoulders, considered that this attending was being the worst kind of cowboy, and left to get some sleep.

The next morning, we discovered that the patient had suffered massive intra-abdominal injuries, severe enough to make him septic within hours of his reaching the hospital. Due to various considerations, our best efforts had failed to diagnose the problem. That attending operating on him – jumping blindly over the cliff, just to see what he would find – saved the patient’s life.

Lately, he’s doing better. He’s alert, which is more than he was for many days after admission. His abdomen looks like it might eventually – weeks or months from now – recover. He’s not septic anymore.

We were ready to give up on this guy. I still can’t believe that he’s actually likely to leave the hospital now. Along with the whole idea of not giving up on people till you’ve given them every possible chance, I learned from the attending: a surgeon’s job is to operate. That’s the reason our patients belong to us, because a lot of them really do need surgery. There’s a place for not operating without investigating first and having some idea what you’re going in after; but sometimes, cowboy is the only way to be, the only behavior that will give your patient a chance. Trauma is a surgical field because trauma victims often need to be operated on. When in doubt, cut (or think seriously about doing so). I’m still trying to figure out how much weight to give this lesson, but it will stick with me for a long time.

There was another patient like this last month, too, on the vascular service. He’d had a simple operation, and three days later crashed into the ICU overnight. We had no idea why. We couldn’t figure out what about the surgery he’d had could possibly be making him so sick. In desperation, the vascular surgeon consulted one of the general surgeons, who looked at the patient and the labs and scans for about half an hour, and then shook his head. “I don’t think it will do any good, but let’s call the OR for an emergency case. We have to at least look.” And sure enough, he had a perforated ulcer that had somehow randomly developed at exactly the same time that he came in to get a vascular problem taken care of. That patient also would have died within hours if the general surgeon hadn’t decided to take a chance and just look, to make sure nothing was missed. CT scans are so fancy nowadays, we think if we can’t see it on the scan, it isn’t there. The younger surgeons and residents especially tend to forget that some things can only be found by putting your hands inside and touching the problem.

I have a new diet plan. It’s called: come in to work so early you’re not hungry, start in the OR so early there’s no time for breakfast, operate straight through lunchtime, and spend the end of the day running so hard to catch up that there’s no time to eat, and you get out too late to eat much dinner. Actually it doesn’t work too well, because then I get tired of not eating, and very depressed about peanut butter sandwiches and ramen soup, and I let myself believe that Chinese takeout is healthier because it contains vegetables.

The day was crazy. I found myself once again holding a retractor and the suction while blood spouted all over me and the attending (more him than me, which was somehow comforting) and the anesthesiologists started spinning around up top, which is usually a bad prognostic indicator. The scrub tech calling for more suction canisters is also a bad sign (because the first set of canisters is full of blood).

In between demanding what I thought I was doing, letting blood get in the field, and demanding what the scrub tech thought she was doing, not handing him five different things at once, he was angry at himself for getting into that situation. I’m not sure it was really possible to foresee the events, or if foreseen, to prepare any better (we at least had blood on hold; not always necessary in general surgery, but always a good idea in vascular); but if he missed something, I did too. It was nice that he blamed himself and not me for the problem, but I remind myself that I can’t keep taking refuge in that. In four weeks, I’ll be responsible for getting patients from the ER to the OR, and all the preop planning will be in my hands. In four years, I won’t have anyone to fall back on. I need to think ahead more.

I sense impending burnout. There’s a limit to how many days in a row you can work 16 hours at top speed continuously. It’s ok, though, I’m planning to be out of patience in two days – the end of this service. I’m going to miss the people a lot, but it will be nice to change pace. (Not that the trauma ICU in June is likely to be any kind of improvement.)

Memorial Day weekend + the first good weather in a few weeks = traumas galore. And if you bring in enough trauma victims, sooner or later you’ll find enough serious injuries to keep the ORs running. Ortho, neuro, general surgery – the attendings were resigned, the residents were fairly cheerful, but the techs and circulators who got called in for backup and more backup when they were trying to sleep were not exactly pleased.

In addition to the trauma scene, the black cloud that’s hanging over the surgical services continued to rain. The ER couldn’t tell what had come over us: we spent the day in the ER, admitting like there was no tomorrow. Every time they gave us a name, we took one peak and said, “Yeah, sure, it’s our patient, they’re sick, it’s our problem, call for a bed.” No discussion, no fights. I don’t think we even looked at the labs. They’re sick, bring them in. No question about it. At one point one of our attendings was even walking through the hallway looking for patients. The ER had barely sat them down on a chair in the hallway before we agreed to admit. (Ok, those were surgical complications, and they’d called the attending before coming in. Streamlines the process, for sure.)

And in the OR, we just gave up on keeping track of night and day. Another case? Sure, book it right now. At one point, my attending and chief looked at each other and said, “What gives? It’s 2am, we’ve been in here all day and all night, let’s just do the next add-on case now, instead of waiting till daylight, and then we can all round at 5am and maybe leave the hospital.” That didn’t really work out as well as expected. . .

The junior resident was nearly overwhelmed with calls, and started handing me his work, and I took it, and looked down the calendar a month. I thought I was getting slammed with calls and admissions; he was hearing all my reports, plus the other intern’s, plus a constant barrage from the ICUs. I am not looking forward to that.

I’m making a resolution, to stop talking to anyone (in my real life) about how unprepared or puzzled I feel. “Professional” covers a lot of ground, and it includes acting like you know what you’re doing, and not letting on to the nurses or those junior to you that you’re scared and confused by a situation. I was on call Sunday, July 1st last year. I was so lost; I didn’t even know where the units were. I got stat pages, and was running in circles around the elevators trying to figure out how to get to the patient, or where a phone was so I could ask the junior for help. The greatest thing about that day was the junior. He strolled around (this is a different one; strolling is good) and calmly sorted out everything I said. I realize now that it was his first day taking call like that, and he must have been at least as stressed out as I was, figuring out what to do with the ICUs. But he didn’t show me any of that. He acted as though everything was under control, and he could help with anything that happened. So that’s going to be my gift to the new interns: I’m going to try to act as reliable and cool as that, because if I let us add my worries to theirs, we won’t be able to function. Plus, if you act calm and intelligent hard enough, you actually will be calm, and at least semi-intelligent. Sometimes, now, I tell the medical students that I don’t know what’s going on. I’m not going to do that anymore, to students, or to the new interns. If I don’t know, I’ll be quiet; but I won’t talk about it. (But I will call the chiefs if I need help; that’s different.)

If Memorial Day was bad, I can’t imagine what Fourth of July is going to be like: bigger parties, better weather, and residents newly promoted everywhere. . . Please, folks, if you have to ride a motorcycle, wear a helmet. That way at least you’ll be able to wake up and talk after we repair all your broken bones and arteries.

I am, with laudable restraint, not going to tell the latest story about an ER mis(sed?)diagnosis. Suffice it to say that even attending surgeons were going out of their way to look at the scans and read the notes and laugh at it. Actually, sadly, I think we’re laughing to distract ourselves from the patient’s truly tragic situation. As the primary service, we can’t avoid dealing with it; and it’s not pretty. But I’m encouraged not to join in the scoffing by trying to figure out what I, personally, would have done differently if I’d seen the patient at the beginning; and I’m not sure I can think of anything, other than a wild shotgun approach to every elderly patient with a vague complaint; which is definitely not a good conclusion. It’s easy to look down our noses, too many hours later, and with all the tests in, and the surgery completed; but had we been consulted, even six hours sooner, we might have missed the diagnosis as well. Too bad that the patient had to start circling the drain in a full-blown syndrome before the lightbulbs clicked.

Yesterday I got to do my first-ever arterio-venous fistula (used for access in dialysis patients). It was with the most legendary attending at this hospital, the one revered by everyone, and feared by most of the residents. As one of them told me, “Operating with him is like eating spinach. It’s good for you, and it makes you stronger, but it’s not a whole lot of fun at the time.” Several senior residents, hearing that I had somehow drawn a fistula with him, stopped to share stories about his teaching methods in the OR.

Suffice it to say that, concerned as I had been to start with, they certainly succeeded at putting the fear of God into me. I spent an hour in the library reading everything I could find on the subject (not much, actually, for a procedure so commonly done), and memorizing the name of every venous branch and tiny cutaneous nerve in the arm. (Did you know that anatomy books never show arteries and veins in the same drawing? What kind of good does that do?)

At length, I showed up for the case. The attending gave me the kind of look that interns get when they show up for cases over their pay grade with attendings who were previously blissfully unaware of their existence. “Have you ever done a fistula?” No. “Have you assisted with a fistula this year?” No. (Not an intentional omission; although truth be told, these things only have room for two people; even medical students rarely watch or assist on them.) “Do you have any loupes? [special magnifying glasses]” No. “Have you ever sewed with 7-0 suture?” No. “All right then.”

I don’t know whether my studying paid off with some semi-sensible answers, or whether he gave me up as a hopeless case, because he did very little of his usual badgering. He did, however, let me sew the entire anastomosis, in 7-0 suture, with no loupes. (This suture, although actually a decent size for cardio/vascular surgeons, who can get down to 9-0 and 10-0, is small enough that the middle-aged scrub techs have to hold it five inches from their face in order to be able to see to load the needle-drivers.) It was also the first time I’d held vascular instruments (which are extremely delicate, and configured entirely differently from the usual needledrivers, pickups, and scissors). So I think that means I did a good job.

Unfortunately, I think I also fell in love with vascular surgery. Silly, Alice, why did you go and do that? I thought you hated watching the endovascular cases. Well, just watching; they might be fun to actually do, the way all the pieces slide inside each other and inside the patient like a watchmaker playing Russian dolls. I thought you were going to make a wise lifestyle decision this time, instead of falling for a specialty which, of all others, is guaranteed to get you up at night with genuine emergencies.

But those blood vessels are beautiful; and that tiny suture slipping into the right place, with those itsy-bitsy needles – ahh. The way the delicate thin vessels magically seal against the pulsatile blood flow because of your stitches. . . The multitude of different surgeries you can do (vascular surgeons, unlike the rest, never ever run out of options.) . . The analysis and decision-making involved in even a “simple” case like a fistula . . . I thought I didn’t like invisible suture and stitches so small that even steadying your elbows on the table is barely controlled enough. . . guess I was wrong about that.

I’m trying very hard to hold on to my original appreciation for plain general surgery, or if not that, then some specialty with decent hours. But now I know why half the residents at this program plan on doing vascular surgery. It probably also has to do with the best attendings, at this program and others, being vascular surgeons.

Addendum: I henceforward swear not to mention stories about the ER, at least not on this blog (I’m afraid interagency sniping is a fact of life in the hospital). After I wrote the above an ER friend called to chat, and to vent about her own frustration with a different surgical team at my hospital who last week, by her description, grossly misdiagnosed a patient of hers (although higher levels intervened in time that the patient is doing as well as possible). So actually I guess the score between surgeons and ER, for diagnosis and correct management, is still even. I’m just going to stop talking about this at all. (Funny, though, I trust my friend, as an ER doctor, more than I trust a few of the surgery residents, as surgeons. I believe her version of events. I wonder if it would have changed anything if I’d been the intern she called, instead of someone else; if having a real relationship between the two sides would have improved the exchange of information.)

Dr. Xavier is renowned for his complete calm in all circumstances (certainly a valuable attribute for a vascular surgeon). On the other hand, he’s also very difficult to read. I’ve given him now a good many opportunities to chew me out, and he never does. But I’m not sure that his calm remarks aren’t his own method of being quite upset. And anyway, do I really want to know?

He’s a tremendous teacher. Even when the case is too difficult for me to be doing anything (like the endovascular cases I’ve mostly been with him for), he’s teaching continuously. “This wire is special because it slides easily; you manipulate it with your fingers like this. . . When you encounter this kind of anatomy, it’s useful to try this little trick. . . This type of pathology is almost always due to xyz; intervention is successful, but only in the short term. . . “

He is, of course, also the guy who keeps telling me to put one finger on the artery, as though that will control the bleeding. I’ve decided that he himself is so calm and phleghmatic that even when he has his whole hand clamped down on the spot, he only feels as though he’s using one finger.

There are several legends circulating about him, mostly along these lines: An open case, hairy circumstances, unstable patient, and some unfortunate resident tears something, so that blood goes spurting all over the place. He places one hand just so, stops all the bleeding, and as he holds out the other hand for an instrument, he remarks quietly, “Generally, John, one tries to move the instruments very delicately so that this kind of injury doesn’t occur. It can be dangerous for the patient, and often makes the operation more difficult. Why don’t you tie a knot here? If you hold the clamp like this, it’s less likely to slip and cause tears. Please put a clamp on that vessel right there. Another tie please. You see this particular vessel is particularly prone to injury because it courses like this through here. . .” All without speeding up either his actions or his speech, or changing his tone of voice at all.

Chalk that one down for a learning experience.

The fact that we had admitted half a dozen patients the previous evening, and booked nearly all of them as add-ons in the OR should have been a clue that it was not going to be an easy day. Nevertheless, the plan was for all the other residents to be in the OR, and me to do work on the floor until one of the last cases, when I could do a minor amputation. Which was fine with me. Amputations are exactly the kind of case where they let the intern do the whole thing.

So I was just hanging out and watching, unstressed, letting everyone else worry about the busy ORs, when one of the seniors paged me: “Hey Alice, Dr. X had to go do this, and Dr. Y had to cover that, so I’m going to be with this other attending. . . so you need to go scrub in OR 12. All right?” I started explaining how thrilled I would be to work with the attending who had OR 12 booked solid for the day, and he hurried off.

It was supposed to be a simple case: access the artery, do an angiogram, maybe put a stent in, get out. I’m starting to learn that nothing in vascular is that simple. If these patients weren’t complicated, they wouldn’t be having vascular surgery. The procedure took twice as long as planned due to difficult anatomy. Finally, we were pulling all our wires and sheaths out. “Alice, just put your finger on the artery here while the nurse gets us a suture to close it with.” Famous last words. This is the third time Dr. Xavier (we’ll call him) has told me something like that, and every single time it ends with blood all over me and the patient. So I put several fingers and a good deal of pressure on it, and somehow there was blood coming out anyway. I’m not sure what happened next. I can’t believe that either Dr. Xavier let go of the proximal controlling loops, or that I was so stupid as to pick up my finger to see where the blood was coming from. However it happened, the next thing I knew there was a fountain of blood all over my face, my neck, my gown.

I pushed the rest of my hand over the artery, and it stopped. Dr. Xavier calmly looked across the table at me. “Carla, would you clean off Dr. Alice’s glasses please?” Silence throughout the OR. “Actually, perhaps it would be better if Alice went and washed off.” Grateful for the confirmation, I let the student get his hand on the artery (with a very determined look on his face), and scurried out to the scrub sink to wash my face.

I thought I had most of it fixed, but as I walked through PACU, pre-op holding, and the nurses’ lounge to get to a bathroom (they don’t provide much for female physicians at my hospital), I got some weird looks. Come to find out I’d missed large sections of the carnage, and looked like nothing so much as a zombie from a horror movie. Back to the sink. . .

A couple of CRNAs standing by assumed I had been banished from the OR in undeserved disgrace, and tried to comfort me. “Are you ok?” “Oh yes, I’m fine. I just should not take my finger off the artery ever again; stupid of me.” “Oh dear, honey, I’m sure that’s just what they said; it’s ok.” “No, I mean it seriously, I should not have taken my finger off the artery. On the other hand, I made a hole in it in the first place.” “It’s not that bad, I’m sure it wasn’t your fault. They’re just choosing to blame you.” “No, really, we made the hole on purpose.” “Oh. . . well, I’m sure it was a learning experience.” lol, talk about crossed wires.

Moral: never assume that any vascular case is going to be straightforward enough not to need a shield on the mask. But I hate the way those shields hit my glasses and pick up glare. . .

 (If you want to hear an even bloodier story, click here.

I am inordinately pleased with myself, and much more optimistic about my future as a surgeon. After the blunders of the last week, something went very right. The chief and I found ourselves elbow-deep in a difficult case, and I was the one with the bovie. (Surprisingly, the junior person is often the one cutting, because the other surgeon needs to have their hands free to see and feel what’s happening and give directions.) The medical student was providing much-needed retraction (you guys have no idea how wonderful it is when you hold the retractors right, and we can really see what we’re doing), so I had both hands free to do surgery with. There was a difficult angle to get across, so for quite a while I found myself guiding a kelly (clamp) with my right hand, and using the bovie (electrocautery) - by now literally a foot long – with my left hand. It went a little slow, but I did the job nearly as well as I would have done with my right hand. I asked the chief later if there were any technical improvements I could make. He said he supposed some speed would come with time. I said yes, it was a little difficult using my left hand. He didn’t even realize I’d switched hands. So I’m happy; I can apparently use my left hand well enough that the awkwardness doesn’t show (title pun intended). And it was a big case; I was so thrilled to have been involved, even after I had to scrub out to go see consults, I was nearly skipping down the halls. But that would be indecorous and unprofessional, so I stopped myself when anyone else was in sight. I wonder what the security folks watching the cameras thought – escapee from the psych ward?

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