surgery


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. . .

We’re going to try again with the more-frequent-posting concept. Exercising, eating, and sleeping, not to mention studying for the ABSITE, do compete for time. I slept a whole extra hour the other night, and felt on top of the world all day. I ought to try that more often. . .

I’m on the thoracic service now, which seems pleasant enough: busy enough not to get boring, but not as overwhelming as cardiac. I actually get to do some cases, which is surprising and nice. On the other hand, there isn’t the liters of blood in the chest tubes that we had on cardiac, and not the same propensity to go rushing back to open up the same incision you just closed a few hours before; so I’m in adrenaline-withdrawal.

Studying for the ABSITE is occupying more attention (or at least, procrastinating about studying). A friend who I think is very intelligent, in practice a good doctor, and could spout all kinds of data and treatment algorithms by heart, failed the written boards. I was scared just listening to this person studying – I’ve never studied that hard. And now they failed, after all that work – I am going to be in so much trouble . . .

I was scrubbed in today for a while, and witnessed the most violent outburst of anger I’ve seen in four years spent around some pretty volatile men. (I say witnessed, because as far as I can tell I wasn’t too close to the center of the target; I’m not sure how much he blames me, but we’ll see about that tomorrow.) My first reaction, besides shock at the amount of cursing, was, “how did he ever get this way? I can’t imagine ever getting to the point of being this angry, or expressing it so openly.”

And then I realized that I’m probably a lot closer to that attending than I would like to think. For instance, the other morning, I had to do several procedures with a nurse who probably qualifies as my least favorite ever. There are some nurses I dislike because I don’t think I can trust their medical advice (ie, they’ll say, “Dr. X would always start z medication now,” whereas in fact Dr. X hates that medication, and anyway it’s not at all indicated at the time); there are others whose opinion I might trust, but I dislike the fact that they are never available to help with problems in their rooms or their neighbors’. This particular nurse qualifies on many levels.

The harder I tried to get all the pieces lined up to get the procedures done in her room, the more ways she seemed to come up with ways to frustrate my efforts (I will allow that she was probably doing this unconsciously, in a sincere attempt to take good care of the patient; nevertheless it added up to thwarting all of my attempts to work efficiently). Finally, I was so angry and tense I would have been happy to throw some trash on the floor, except I knew that would bring our conflict way out in the open, and put an end to any forward momentum at all. As it was, I doubted that I would be able to do the procedure safely, I was so upset.

That morning, I got past it with a few prayers, and some meditations on the insignificance of these procedures to the course of the day, and how it didn’t really matter if I spent an extra fifteen minutes doing them safely.

But I can easily see how, if I had the power to throw things and yell without fear of retribution, and if the procedure I was doing was far more weighty and vital, I might well have chosen that as a method of venting stress, reasoning that it would be better to get it out so I could go on to concentrate on the procedure, rather than trying to keep it politely in, and be so tense that I couldn’t control my hands properly. I can even see how enough of these experiences as a resident, controlling anger, and then watching my role models express it, could make me happy to do the same when I reach that level. (This deliberate choice of a method of stress relief, to get back to the job at hand, would also explain the curiously swift changes of mood of most surgery attendings: they get very angry, then they calm down, and are back to joking and friendly. A few of them don’t let go, and they’re the really scary ones.)

I hope not. I know Paul said “be ye angry, and sin not,” and I’ve got to think that throwing things in the OR, even if only at the floor and not at people, probably counts as sinning while being angry. (Irony there, folks. I know quite well that it’s wrong. Don’t want you to get too concerned about me.)

I’m not old enough to be doing this much reminiscing, but something about having spent two years at this is making me retrospective (is that an adjective?). In medical school we changed specialties every few weeks. It’s still a bit funny to be spending years straight on one thing, and to plan to spend even longer on an even smaller area of that. . .

Anyway, when I was a medical student on surgery I was fascinated by the trauma service. Most medical students who have any procedural (or should I say violent) bent at all are; they’re attracted by the excitement of the trauma bay, and the acuity of the ICU. They don’t understand how the residents get frustrated by caring for geriatric and head injury patients instead of doing surgery.

So it was July, and I was supposed to be doing something else, but I decided to spend the night with the trauma team; their assigned medical student wanted to do peds, and had no interest in contesting my presence. A patient on the floor needed a chest tube. It was one of the first for the intern, so there was no chance for me to get involved, but I went along to watch. The main thing I remember was the violence of it, and how the patient seemed to be having so much pain. As a student I couldn’t tell for sure whether the surgeons had premedicated him adequately or not, but I was a little shocked by how they all focused on explaining the steps to the intern, and getting the tube in, and seemed not to care how much the patient was grimacing.

We had a chest tube to put in on the floor today. I always hate chest tubes on awake patients; at least in the trauma bay the gunshot victims are short of breath enough to understand that something needs to be done quickly. On the floor, the problem isn’t that acute, and it’s harder to justify. This lady certainly qualified. Her effusion was occupying nearly 70% of her thorax. I made sure the nurse gave her some medications ahead of time, so they could take effect while we were laying out our supplies and setting up, and I did my best to let her know what would be happening.

But I was thinking more about the technique of the insertion, and how angry I was that the fellow felt the need to supervise me. For crying out loud, I’m a third year resident now (just two weeks and I already feel confident calling myself that). I put in a dozen chest tubes just last month, assisting the trauma team at night. I know how to do it, and how to do it quickly. I know about numbing up the periosteum and the pleura, about entering the chest over the rib rather than under it (to avoid the intercostal artery and nerve), about dilating the tract with the hemostat, angling the tube in so it goes up and posteriorly, and suturing it tightly down afterwards and putting an occlusive dressing over it. I don’t need supervision anymore; and especially I don’t need this guy, neither whose character nor whose knowledge do I respect, chattering away giving me superfluous instructions (the opposite of what the last three attendings told me), and disturbing the patient by the graphic nature of the instructions. She doesn’t need to hear about how doing it the wrong way will cause excessive bleeding, while it’s being done.

It went in smoothly, for all that, and the only commotion came from the fellow, not me. Despite adequate iv pain meds (she was as sleepy as I could tolerate on the regular floor), and plenty of correctly applied local anesthetic, she wasn’t really comfortable. The tube irritates all the pleura it touches, not just where it goes in. But once I was sure she’d gotten all the meds she could, it was more important to finish the procedure in a timely manner, and technically correct, than it was to spend time trying to calm her down. Once I was done, the pain would alleviate. So here I am, just like those residents I wondered at only a few years ago. I don’t know if that makes me heartless, or a good surgeon, or both.

Another small instance of the difference between medical and surgical approaches to hospital life: the history and physical, familiarly known as the H&P. This is supposed to be a complete summary of the patient’s current problems, past medical/surgical/social history, medications and allergies, physical exam, and available laboratory data. To the internist, especially the residents, this is a work of some detail, which can occupy a few hours, and comes to several pages when written out fairly.
 
To surgeons, on the other hand, it’s a task to be finished as quickly as possible on the way to somewhere else. The rules quite reasonably require that one must be written and on the chart before the patient goes into surgery, as there are many things which will need to be known while the patient is still unconscious or unable to answer coherently. Thus, I have written an H&P in five minutes while waiting for anesthesia to get an iv into a vascular patient with a tourniquet on a bleeding limb before we go back to the OR. On the trauma service, one fills in the checkboxes on a form in between resuscitating the patient, entering orders, and paying close attention to the CT scan in progress (usually a good deal more attention is given to the CT than to the form). Even under routine circumstances, I’ve worked it down to an artform: I have my own mental template, which I scratch out on the paper and fill in known points while flipping through any paperwork that came with the patient, then scribble in the rest while talking to the patient, and fill in the physical exam bit while talking to my attending on the phone. 15 minutes, 20 if complicated. (In fact, this is one of my most standardized private methods of assessing the interns, in addition to how omniscent they are on rounds: how fast can they write an H&P? I’m a little despondent about the ones who still, at the end of the year, spend 15 minutes talking to the patient, then another 10 minutes writing things out, and only then are they ready to do orders or move on to another job.)
(Speed should not be at the expense of thoroughness or completeness. I’ve also worked out a few key questions to elicit the information that patients tend to forget, or consider not worth mentioning: a medication list is key, since it will show up all the major medical conditions (so many people feel that if their blood pressure is treated, they don’t have to list it as a problem; or elderly people may not know that they’ve been diagnosed with heart failure, but the combination of lasix and a beta blocker will suggest the possibility); are there any other surgeries you’ve had; do you have diabetes?; anything else you’ve been treated for? etc. On the plus side, if you need an H&P really fast, the history of present illness is usually pretty quick and obvious, eg patient fell and cut arm on glass 3 hours ago and has had tourniquet on ever since then, complains of numbness and paralysis in arm. Plan, will go to OR right now.)b

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