surgery


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

I guess my communication style can’t be that bad. The family involved in the conversation that inspired my last post said so many good things that the attending complimented me on it – and it has to be pretty good for an attending to go out of their way to say something positive.

Then today I was operating with the most demanding attending in the program. All the residents, even the most senior, are a little scared to operate with him, not because he’s mean, but because he has such high expectations, and doesn’t stop pressuring you. For the junior residents, being intellectually lazy, sometimes we’d almost rather not operate, than be with him. But today, I thought the comments were at a pretty minimal level, and after he left the room, the tech said, “It was so nice to have you today. Thank you for doing such a good job.” I said I thought I’d been remarkably slow, and the nurse responded, “No, compared to days with other residents, this was very smooth and quick.”

Which has given me so much job satisfaction, and no doubt a big head too, that something bad will undoubtedly happen shortly. The end of the year tends towards pride and stupidity; all the residents start to think about the new status they’ll attain in July (attending, fellow, chief, not-the-most-junior, not-the-intern), and correspondingly have far too good an opinion of themselves and their judgment. I can see it in myself and my colleagues, and yet I can’t quite stop myself from feeling extraordinarily satisfied that in less than two months I’ll be a third year resident, only one year away from fourth year, and that’s only one year away from the fifth year, and before you know it I’ll be done. . .

Before we started the third year of medical school, the clinical years, they had us do a workshop on breaking bad news. We had to (individually) tell an actor portraying a young woman that she had melanoma, and then help her deal with the shock of the diagnosis, and get her to understand a bit of the prognosis and the treatment plan. I did pretty badly, as I recall. I blurted out the news baldly, and then sat there, unsure whether to hold her hand, and unable to control the conversation enough to communicate anything else meaningful through her (very fake) tears.

I don’t know if I’m any better at it now, but it’s not for lack of practice. In surgery, there’s a lot of times when people come to see you, somehow not realizing that if they’ve been sent to a surgeon, they’re going to have surgery. Whether it’s in the office, or the ER, or a consult in the hospital, I’ve had a lot of conversations along the lines of: “We now know what the problem is, and you need to have surgery in half an hour/in two hours/tomorrow/next week. The risks of surgery include, but are not limited to, death, serious injury, abscess, wound infection, respiratory failure. Please sign the paper.”

That is of course merely an outline. Depending on how much time we have, I try to spend a little while explaining the diagnosis, and how it leads to surgery, so that it doesn’t seem like we’re recommending this out of the blue – that there is in fact a reason for the commotion. Then I explain what we’ll do during the surgery; depending on how much blood and guts is involved, I may edit this extensively. Then the consent, which always sounds bad inside my head; if somebody asked me to sign a paper accepting all those risks, I don’t think I’d cooperate.

The more of an emergency it is, the sicker the patient usually is, the less likely family members are to be handy, and the more of a rush I’m in. Usually, after calling the attending and the OR, I have half an hour to get the consent signed, have my note written on the chart, get blood drawn for type and cross, a last minute EKG if needed, antibiotics ordered (and call the pharmacy and explain that I mean now, not tomorrow), get the patient transported to pre-op holding, and a quick talk with the anesthesiologists about what we’re planning and what kind of lines might be needed. Plus answering all the other pages I’m going to get in the meantime.

So sometimes, like last weekend, it really does boil down to this (at the top of my lungs, because of course the elderly patients are all hard of hearing, more so under stress): “You have a very serious problem, and if you don’t have surgery you will almost certainly die very soon. You need to have this surgery, right now. But even if we do our best, there’s a very high risk that you will still die, or end up in the ICU, even on a ventilator, for a couple of weeks. Do you understand that? Ok, please sign.” (That was for mesenteric ischemia – dead gut, which had already been sitting around for a while. And then the nurses found the DNR papers, and I had to persuade everybody that since the patient had just insisted that they wanted to have surgery, and wanted everything done, the DNR orders were implicitly revoked, and it was ok to intubate for surgery. Why are DNRs always there when you don’t want them, and never when you need them? Fortunately for all concerned, our preop assessment turned out to be an overestimation of the seriousness of the situation, and the patient spent only one day in the ICU.)

Which is all to say that, as in my medical school days, I’m still trying to figure out how much time to spend commiserating and comforting, and when to move the conversation on to what our plans are. Sometimes it’s easier to have the pressure of the impending OR to set the timetable.

I was going to stop blogging entirely, but my mother wouldn’t stand for it, and I discovered I’ve developed an intractable habit of telling stories in my head, and without this blog, there’s no one to tell them to. So I guess we’ll keep going for a while. (When I found myself seriously trying to talk medical students out of going into surgery, that was really full circle. . . but maybe there’s something beyond the circle.)

Vascular surgery is the most complicated inpatient service to try to run. For one thing, trying to doppler for pulses takes a lot longer than checking to see whether people have significant abdominal pain or not. For another, the patients have all the usual surgical issues (wounds, getting out of bed after surgery, pain control, post-op fevers to worry about), plus a lot of medical issues. It would be unbearably unwieldy to consult medicine on all these patients, who usually are well looked after as outpatients by doctors who don’t round in our hospital, so the junior house staff get to keep an eye on the medical things: blood pressure, blood sugar, etc.

And then there are the things peculiar to vascular surgery: which patients are on aspirin, which ones need plavix (in many cases only riskier, not more beneficial), and which ones are supposed to be on both, as a step below coumadin; which patients are on a heparin drip, which ones need it stopped for surgery tomorrow, which ones need it started the day after their surgery not the day of; which patients aren’t on heparin at all, but lovenox instead; who needs lovenox arranged for home (it’s tricky to set up with the insurance companies; I love case managers); who is on coumadin, and of those, who is getting 2mg, and who 10mg, who’s at a therapeutic INR, who’s overshot and skipping a day (but don’t forget to write for it tomorrow), and who’s still slowly working up to the right INR. . . If you get any of those mixed up, the patient will either start bleeding catastrophically, or else clot off their leg; and of course they could do either of those anyway, even if you get it all right.

I got to do a small case the other day, and after some bleeding developed, I was internally congratulating myself for not panicking, and not simply staring at it, but quickly putting my finger on it, till we could get suction and forceps and a stitch together. Afterwards I realized that my eagerness was overkill, since the blood was only pooling out of the incision, not shooting at the ceiling; which means, for vascular surgery, it didn’t count as real bleeding at all.

Someone once sent me a package to Dr. Alice, so when I called FedEx to explain that they couldn’t just drop a package addressed to Mr. John Brown, whom I don’t know, at my door, simply because the addresses are similar, the lady on the phone recognized that I was a doctor, and started chatting. She wanted to know what was my least favorite kind of surgery (so yes, silly of me to admit that I’m a surgeon; which actually suggests a whole other line of thought, about why doctors are secretive 1) about their profession 2) about their specialty; my father has a fairly sound theory that if you’re admit you’re a doctor, people assume you’re rich, and automatically start looking for ways to get money out of you; which, as a man with a large family, he couldn’t afford). Her question nagged me, partly because of course I couldn’t tell a stranger on the phone about my patient who just died after surgery, or how I hate cancer surgery because of the times when it doesn’t work, or how nasty dead gut is, or how I get stuck with the abscesses because I have no sense of smell, or the nightmare of burn surgery which I’ve pretty much blocked out of my memory; and partly because it reinforced my growing sense of surgeons as a separate species.

Which I’ve been thinking about on this rotation. We often end up having to tell people that they need a section of their intestines removed, for various reasons. People are attached to their body parts, oddly enough, and don’t react well to the proposition of losing some. “It’s good for you,” so we insist, and explain, and persuade, and eventually end up doing what needs to be done. But people give us these looks, like: are you crazy to suggest that? And I guess we are. We have crazy ideas, and do unnatural things, and we’re different from normal people.

Hopefully I’m just at an intermediate stage of development with this. To medical students, it doesn’t kick in, because they spend a relatively short time on surgery, and there are so many strange things going on that it’s all equally crazy. And to attendings, this is normal, because they’ve been doing it for so long. There’s just an awkward phase, where I still have a vague memory of normality, and haven’t quite adjusted to my new tribe. The other residents don’t seem to feel this way. Maybe they wouldn’t say anything if they noticed; or maybe I really am crazy. I criticize some of the interns, for having an off-kilter angle on reality; but maybe I’m off-kilter too.

And I’m not going to get to operate this month, so there’s none of that excitement to mask the oddity.

I have become my own old enemy. I used to wonder at the residents riding the interns and medical students – how could they be so harsh, when they had so recently come through the same thing themselves.

I know now. First, it doesn’t seem recent anymore. Intern year is a rapidly fading memory – let alone medical school. That was a different person, in a different galaxy. And second, I’ve realized that my program and my hospital will deteriorate rapidly if the interns aren’t taught surgical ethics. My seniors taught me – forcefully – about work ethics, responsibility to patients, responsibility to team members, deference to attendings and chiefs. I didn’t enjoy hearing about it when they thought I was out of line; but now I appreciate the strength of the standards they passed on – and I want the interns to learn the same thing. In a few months, they won’t be interns any more; and if my class has failed to communicate what seem to me basical principles (don’t leave till the work is done; don’t leave without signing out your patients properly to a responsible person; don’t walk away from a patient whom you’ve just decided to transfer to the ICU; don’t forget to write a note about any important patient encounter, or any procedure you do; don’t assume that the ER will get a patient to the OR quickly, or with appropriate medications; don’t assume. . . anything) – then they can’t teach it to the next class of interns.

I like my hospital, a lot actually; I feel very possessive about it, especially alone at night in the dark hallways; and I want it to continue to provide good care. Which is why my interns and medical students are going to find me being stricter for the rest of the year.

Sorry guys, short on further stories. I think at some point it has to get tiresome to an outside observer to keep hearing how excited I am about simple things like hernia repairs (well, ok, not simple, but today I finally managed an important step in the procedure myself, without the attending handing it to me).

Other than that, I am disappointed to observe that I have become as cynical as any jaded resident I’ve ever watched and wondered at. Maybe it’s the time of year. I’ve had conversations with nearly all the junior residents in the last week or two, discussing our regrets at being in surgery, and our fantasies about what we should have, or perhaps still could, do differently. Some of my colleagues had remunerative careers before going to medical school; unlike me, leaving is at least theoretically an option for them.

As for students, I make no effort now to attract medical students. If they’re enthusiastic, I’ll help them find where the most interesting things are; and I’ll always answer questions. But I have no patience for the silly ones, who talk as though they know something only to reveal their own ignorance, or who are so bored by the whole concept of surgery that they walk off in the opposite direction while the intern and I are pulling up a CT scan to see if we can confirm a diagnosis of appendicitis. (I mean, come on; CT scans are fun. You can always learn something by looking at a scan, especially a positive one.) I did grab the student and make him look at the appendix (classically swollen and inflamed, in this instance), but I had no energy to carry on to general principles of reading CTs, or general principles of how to behave when seeing a new consult with the team. As far as career choices, I haven’t even finished second year, and I’ll advise anyone to do something other than surgery.

And medicine interns. Don’t get me started on them. It makes me so angry when they write an order for a stat surgery consult, and then walk off, leaving the secretary to call us, not caring that it may be 12 or even 24 hours later that we finally hear about the situation. As often as not the matter is not urgent at all, but if they are puzzled, or concerned enough to mark the order stat, then they ought to take two minutes to call me themselves. Or, when they consult us for a longstanding hernia in a patient admitted for a completely different matter. We’re not going to operate during this admission. I personally will be off rotation by the time they finally follow up in the office and schedule surgery with my attending; so why do you force me to go through the pointless exercise of talking to the patient, writing up a complete consult note, and then calling my chief and attending to tell them about it? Or when every day they try to feed the patients who’ve just had surgery for a bowel obstruction, and still have an NG in. Such a temptation to write rude things in the chart (which I never do, though).

My friends and I all seem to come to the same conclusion: no matter how tired we are of residency, or of the hours, or of the hierarchy, or of our inability to perform miracles, in the end, being in the OR makes up for everything. There’s nothing else in the world like it, for pressure and power and danger and reward; that’s why we stay. (That, and the paycheck; which of late months is more appreciated.)

(Equal-opportunity grumpiness: the surgery interns sometimes drive me crazy, too. There are a couple that have a knack for always choosing the less correct of two possible options, or of doing whichever thing will annoy this particular attending the most. Then there are some who will call me late in the afternoon to announce that there are four consults on the floor, and two patients in the ER, and maybe one coming in from the office. . . why they couldn’t tell me some of them sooner, I don’t know. But them I have a little more patience with, because I know was, and probably still am, just as annoying in similar ways.)

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