surgery


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

Steering back to safer, less political waters:

I’ve been having a peculiar experience lately. Of course I’ve grown inured to the embarrassment of concluding that a patient needs surgery, and making my case, and then being informed by the attending that I’m insane, there’s no such indication, and the patient is best left far outside the OR.

But recently, I’ve encountered the slightly more disconcerting phenomenon of being told by the chief resident that the patient doesn’t need surgery, adjusting my presentation when talking to the attending, and then being told by the attending that we should book the case for first thing in the morning. Depending on how much I caved to the chief, I then get reamed out by the attending, again, or I get credit for having made the call.

Last night was a succession of such cases. A large bowel obstruction, a variety that I haven’t seen a lot of, which people weren’t convinced was really obstructed, but the attending agreed with me. Ischemic bowel, which the intern and the ER doctor were trying to downplay as questionable, but I knew the CT was incredibly bad, and the patient’s vitals and appearance were subtly hinting at the outcome, which was that he died six hours later despite our best efforts (I can at least be glad that I didn’t waste time, and that I stuck to my interpretation enough to drag both the chief and the attending in much against their wills). A less obvious case of ischemia in a vascular patient, requiring intervention in the middle of the night. . .

Now that I’ve gotten to the seniority, and perhaps the reputation, that the attendings will usually, despite questioning me at length, book the case immediately just on my say-so (because surgeons can’t function without interrogating each other, and especially their junior members, regardless of how correct the plan is), I’m starting to encounter the weight of responsibility: I have the OR set up, the patient consented (often after being talked into it quite urgently; so that I would feel incredibly guilty if I had persuaded them so firmly, and was mistaken) and carried down to preop. Everything ready to go for a major operation, and all on my authority. I make time, no matter how much the ICU is calling me, to wait till the attending comes, so I can see what he thinks of the patient and the CT scan. I only ever once got the patient and the attending together in holding, and had the attending seriously consider cancelling. But I get very nervous at the idea that I, virtually by myself, am setting people up for big surgeries. . . what if I get it wrong?

In one sense it was a bad night, because I didn’t get much sleep, spent a lot of time in the ER, and had my patient die anyway. On the other hand, I surprised myself by handling the problems well. I probably shouldn’t talk about it too much, being just starting into a month of night float, with so many upcoming opportunities to make mistakes and act idiotically. But . . . I talked on here a lot, especially a year or two ago, about how much I admired the senior surgery residents. . . how they took control of bad situations, and knew what to do, and stayed calm. I thought I would never be like them. Much to my astonishment, and I have no idea when or how it happened, I found myself acting like them last night.
 
It was one of those messy situations, where the ER knows the patient being flown in needs surgery of some kind, but the diagnosis is unclear till the patient can be seen and have a CT scan. At least this time they called the surgical services ahead of time; perhaps after the series of fiascos last week our attendings yelled at them enough to impress the importance of calling ahead for ruptured AAAs and such like. (Not that the ER got around to informing the surgery residents, but my radar is getting pretty good.) Which meant that I, also bearing past miscommunications in mind, called the OR ahead and had them getting ready. So everyone was in the right place when the patient arrived.
 
He looked deceptively good for about 30 seconds, and then fell apart. Maybe it was a little longer, because I had time to at least make sure to my own satisfaction that he belonged to my service and no one else’s, so he was mine. Then it was the usual chaos of trying to intubate and do CPR all at once, get iv access, get monitors on, get blood and fluids lined up. . . The ER attending was technically responsible, because we were in the ER, and the patient hadn’t been officially diagnosed yet (I was just extrapolating freehand, taking the most pessimistic interpretation of the available data); but I was responsible too, because I knew if we could stabilize him, my attending needed to operate on him; and if you’re a surgeon and you’re present, you can never blame anyone else for anything that happens. The ER nurses and attendings knew he was ours, so they kept looking to me for directions. Gratifying, but scary.
 
Also I got a central line so fast, despite my hands shaking, that I was almost too surprised to finish threading the catheter. Now the ER folks think I’m magic, which is fine, I guess.
 
I’m not saying I have the calm part completely down; I was certainly pacing back and forth, and – not quite wringing my hands, but touching everything, the ivs, the bags of blood, checking for pulses repetitively. But I didn’t change orders and contradict myself, or give orders too often to be meaningful, and my voice wasn’t squeaking.
 
In the end we stopped. Despite occasional fleeting spontaneous pulses, we weren’t getting anywhere very encouraging with CPR, and it was clear that the patient was never going to be stable enough to move to the OR, let alone even start an operation on, which made further efforts futile.
 
The only thing I really still want to fix is, my voice keeps breaking when I talk to family members. It’s bad enough getting a midnight phone call to say your loved one is dead or dying, you would think the doctor should at least be able to speak coherently and audibly. It doesn’t really do much good for me to call people to give them bad news, and then have my voice be too shaky to communicate anything except that something bad is going on, leaving them to imagine for themselves what that must be. . . I know, sympathy and emotion from the doctor are good. . . but when you don’t know each other from Adam, probably simple transfer of information would be more valuable.
 
I especially hate calling 80-something wives – widows – who you know are home alone in the middle of the night. They’re half deaf, and sleepy, and don’t want to hear that their husband is dead. . . and when they do hear you, you can hear them just about collapsing. . . but so often the wife is the only phone number listed, and if you want to reach the adult children you have to go through her. . . . and you can’t just not tell people, and hope the morning will make it better. . . I have no idea how, but the ER social worker does miracles. She discovered the pastor and sent him over to keep her company. Now that was probably the most useful action of the night (and another profession to add to my list of people besides doctors who don’t get to sleep at night).
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.)

Somebody on a tv show the other day was cutting with the back side of a scalpel. It was a nice big #10 blade, the fat round wide kind (nice, because they slice things right open without the slightest effort), but they were cutting with the back side, which isn’t sharp, and it made a big incision that bled tv blood. I found that very annoying. If you got enough of a scalpel to use as a prop, wouldn’t you notice which side was sharp?

In the surgical world when we cut our hands we don’t use bandaids. You can’t scrub with a bandaid, and you aren’t supposed to scrub with an open wound (more I think because of the increased risk of infecting yourself if the glove is broken, than for the patient’s benefit); and of course you can’t not scrub at all just because you were silly enough to cut your hand. So we use the little plastic tapes that are used to stick ivs down. They’re slim and smooth, and are actually sticky enough that you can scrub for two minutes with one on, and have it stay on through gowning up.

I know this, because somehow, although I think I’m getting to be not bad in the OR, I cut myself frightfully often with kitchen knives, and even with all kinds of objects that you wouldn’t think were sharp, but somehow I end up with cuts anyway. I’m a little disturbed by how awkward I am with everyday objects; but I know I’m not that clumsy in the OR. . . I guess I’m concentrating more there.

Anyway, it’s gotten to the point that I keep a small collection of iv bandages handy, for taping up my fingers.

I’m nearly done with a third of the year spent in cardiothoracic surgery, and I’m counting down the days till I get back to general surgery. People keep asking, and I’m completely unable to explain why; but somehow, the strange fascination that drew me into surgery in the first place makes me most interested in general surgery. I’m looking forward to getting called to the ER to see people with appendicitis and cholecystitis and diverticulitis and abscesses. That’s weird, isn’t it? The CT guys keep telling me their stuff is cleaner – nothing too dirty or smelly in the chest – but somehow it doesn’t get my attention. Maybe because I didn’t ever spend much time with this in medical school, so it never seemed like a part of the real surgical world to me.

Nevertheless, despite having been anxious to be done with the rotation for the last two months, I’ve learned a lot.

- I’ve come to see the heart as a real object, with definite anatomy, and implications of that anatomy for patients’ health. Before, coronary artery disease was a nebulous kind of entity to me, and whether or not a heart attack occurred seemed just as rational as lightning striking. Now, I can read a cath film with some degree of accuracy, and the fellows finally succeeded in pounding into my head the difference between the acute marginal and obtuse marginal branches, between the diagonals and the septals. They’re as solid and real now as the superior and inferior mesenteric arteries: if you block any one of them, the tissue downstream will die.

Similarly, ejection fraction on an echo makes more sense, and the different valves that can be stenotic or regurgitant, and the different types of heart failure that will result.

- I’ve looked at a lot more chest x-rays and chest CTs, and I no longer skim through the lung windows of a chest CT as though they were a gray blur. I finally grasped what ground-glass opacities look like, and bullous emphysema, and some of the distinction between atelectasis and pneumonia.

- I am really good at arterial lines. After weeks of doing a couple every day on cardiac patients with poor peripheral circulation and/or no pressure and/or no pulsatile flow, the radial artery on a patient who’s only hypotensive seems to leap out. Radial lines used to be my least favorite line, and now they’re fun.

- The critical care attendings and the cardiac attendings, in between constantly disagreeing with each other about what pressor is good for what problem, at least taught me the actions of all the different pressors (not just the three most common), and a philosophy of choosing them rationally rather than at random. (I’m just ashamed it took me till third year to get this.)

- As the senior residents promised me all last year when I got too excited about what they considered to be a minor amount of blood, having seen blood pouring out of the heart when it’s being cannulated, having seen an ascending aortic dissection visibly expanding while we were struggling to get the axillary cannula in, having seen four liters of blood cleaned out of an open chest, having seen chest tubes drain one liter in two hours – I have developed the most shocking disregard for an artery or two shooting at the ceiling, or a central line site oozing continuously, or a vascular surgery wound soaking through a couple packs of kerlex. On the other hand, I have a new respect for the power of plasma and platelet transfusions, active rewarming,  calcium infusion, and patience, to correct severe coagulopathies, without the need to operate on bleeding that you couldn’t really improve surgically.

- This skill will probably rarely be of use again, but I am a chest-tube-pulling machine. I can get an armful of supplies, and have ten chest tubes (ok, two per patient) out in half an hour, with no assistance, and no air leaks. Only valuable when you have an ICU full of post-op day 1 heart patients, or an entire list of post-op day 1 VATS patients, but it’s fun to surprise the patients with how easily it goes (usually). Trauma has a few chest tubes, but not this quantity, and by the next time I’m on trauma, I’ll be senior enough to tell someone else to pull the chest tubes. Maybe.

I take back what I said about the janitors and cooks and garbage men having jobs as demanding or exhausting as doctors. Actually we’re quite different. This job doesn’t stop when you go home. Even in this era of sign-outs, and cross-coverage, and restricted hours, the job doesn’t stop when you leave the hospital, or when the clock says you’re off duty.

I’ve spent the last five days, missing meals and sleep at the majority of meal-times and night-times, not because I was required to, but because I couldn’t not. I felt obliged to do some “extra” things – double-check this or that; spend extra time making sure an NG tube was in smoothly, or that there was iv access, or that an xray got done and looked at immediately, before leaving the hospital; driving back in – and back in, and back in – to see people whom I knew logically were just fine, didn’t need me — but I couldn’t guarantee 100% for sure that something bad would not happen, because I had wanted to sleep instead of checking on something. So I checked.

There were times when I could have chewed out a resident from another service, told him to stop being an idiot, take a look in an anatomy book before calling a surgeon to say such silly things, if that’s really how little he remembers from medical school, and do his own work for a change. But I didn’t. I explained politely how impossible his idea was, then told myself that I couldn’t be 100% for certain that he was wrong and I was right, and it would be unforgiveable if the patient got hurt because I was having a turf war. So I went and did his job for him, and wrote a polite note saying a surgeon wasn’t needed.

The point is not that I should have skipped any of those things: they were plainly my duty. But they’re not in the job description, and they have nothing to do with whether or not I get paid. When I go home, I can’t stop thinking about this job, and the nurses don’t stop calling me just because I left. My professional duty obliges me to do all kinds of things that are not part of a timed job.

Like talking to the family of a patient who died. He wasn’t on my service, I wasn’t really there for the death, I still can’t figure out how I ended up being the one doing the talking. But I know I’m the only one of all the doctors involved who knew him as a person, before he was just a disaster that we were working on; and I myself am sad that I can’t ever talk to him any more. And so I went and spent time with his family, all of them in various stages of grief: some unable to talk, some angry and trying to blame me because I’m “the doctor,” some being logical and wanting detailed explanations. . . and the air in the room so dark it was hard to breathe. . .

I didn’t really know what they meant when they started talking about professionalism in medical school. Now somehow I’m here. I don’t know if I was always this obsessive and paranoid (I can’t call myself dedicated or thorough; maybe someone else will, some day); but I am now, and I have to be, and there’s a compulsion inside me, that I caught from the doctors who trained me, and I can’t not act this way.

Hurricane Jill has pinpointed it much better than I’ve ever managed: Surgery is black and white. Either the patient needs surgery, or they don’t need surgery. Either it happened, or it didn’t happen. Either you cut a particular structure, or you didn’t. Jill contrasts this with her pharmacy background, but I think it also contrasts with other medical fields: you can debate which antibiotic has the best coverage, or which beta-blocker works best for CHF patients, and apparently the medical interns at my hospital can even debate how much potassium to give a patient who’s hypokalemic (to me it’s a reflex that happens as soon as the labs come back); you can adjust the insulin coverage gradually, and experiment with different oral antihypoglycemic agents to see which work best for an individual patient. . .

Surgery is qualitatively different. Yes, there’s room for debate, and difference of opinion on the team, or between attendings, but in the end someone has to make a decision and act on it, and deal with the consequences; and usually that decision has to be made sooner rather than later. In the ER, that’s obvious; but even when a patient comes to the clinic, they and their PCP are not usually interested in spending a few months thinking about surgery. They come because they want to have a definite discussion, and make plans that day (or is that transference from our agenda? I think not; if the problem is one that can stand to be watched, the PCP has often done that already, and referred to a surgeon when the patient is tired of nonoperative management). If a patient gets started on a medication, and it doesn’t work out well, it’s not too much of a big deal to change to another one. But if the patient needed surgery, and didn’t get it, you don’t get a free pass back to the status quo ante by proceeding with surgery once you realize your mistake.

I guess it’s not so much that surgery is really black and white, or has hard, clear answers, more than any other medical field, but that even in the absence of scientific certainty, you have to make a decision. There is existential, if not epistemological, clarity. (Maybe that’s too many big words. . . tell me if I got them backwards.)

I always hated grey answers. Some questions I no longer consider important enough to be worth spending time or effort on finding the right answer to, but on the important questions, I have to have certainty. Does God exist? Yes. Is the Bible true? Yes. Should we do an appendectomy? Yes.

I was encouraged the other day to discover that I am in fact turning into a surgeon, and possibly even a competent one. The fellow had been talking me through a procedure, my first time, and it turned out quite simple and easy, perhaps a little to his surprise (I didn’t know enough about it to be surprised one way or the other).

That night I had to do the same procedure, on a patient who was not intubated, and quite jumpy. Let’s just say that it’s difficult to get good local anesthesia if the patient jumps half off the bed every time you get a 28-gauge (ie very tiny) needle 0.5mm under the skin. . . despite some iv sedatives in assistance. And of course this time, in the middle of the night, without the fellow around, the procedure was much more complicated than it had been in the morning. Also, the instrument tray the fellow had advised using contained instruments that were next to useless for the purpose at hand.

So I got to try and keep that patient calm (with the nurse’s very good help), through a procedure that lasted much longer than I had planned on, without letting on to anyone else that I had very little idea of what I was doing, or what I would do if that didn’t work. . . It did work, finally, when I was about ready to declare defeat and go looking for a better instrument set and/or someone senior to me.

Perhaps it’s not reassuring to the public to say, but to me, being able to improvise in a difficult situation, through a procedure that I’d never seen done quite that way before, means I’m learning how to operate, and how to make instruments do what I want them to do. A small step in the path of the legend of the vascular surgeon repairing a ruptured AAA with a set that turned out not to contain any vascular clamps. . . (the legend doesn’t mention whether the patient survived; I ought to ask).

The attending called me “honey” while explaining a difficult step in a complex operation. He apologized immediately, and we ignored it. That was after he said I was doing a good job.

Now, I’m upset, not because I think it was sexual harassment, but because it’s plain that I have failed to behave maturely enough and professionally enough to earn respect from my attendings. The hardbitten senior female residents would not get called “honey.” The idea is hilariously incongruous.

I don’t want to be as tough as they are, but I certainly don’t want to be regarded as a child by the men whom I need to teach me. Perhaps I need to give up on the first wish. I speak as definitely as I can, and keep my voice as flat as possible. Not helping, I guess. I really ought to cut my hair, but I refuse to do that; it’s one of the last pieces of my identity from before surgery. All the really hardcore surgery women have their hair chopped quite short. At first I took comfort from the residents who kept their hair longer, but now I realize that those are the ones who, because of the personalities and career goals that go with keeping feminine hair, are not much respected either.

Trauma rotation, as the senior resident, later this year, should be interesting. I will either break down completely, or I will learn to stay on top of a mountain of acute information without appearing – not flustered, but excited. Perhaps that’s the element I’m missing. I guess it’s childish to be visibly excited about a dramatic problem, or visibly concerned about a patient deteriorating regardless of all efforts. I need now, not just to keep my face still, but to keep entirely still. Resolved, not to walk around while thinking. . .

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