surgery


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.)

Call last weekend was one of the wildest days of my career to date, including some events that I’m literally not thinking about because, despite my predilection for seeing how close to the edge of a cliff I can get without falling over, I don’t dare to examine those events in detail. And that was only the beginning.

The last consult of the day was for an elderly patient with peritonitis. She had multiple other comorbidities, making the idea of operating on her quite daunting. Nevertheless, as I’ve told the medical students many times, if somebody honestly has peritonitis, then they need surgery. So I had to explain to the family, who thought they’d come in to the hospital for just another bout of the stomach flu. The altered mental status, clammy skin, absent urine output and glazed eyes didn’t have the same instant significance for them that they had for me.

Once they agreed that, despite the risks, they would rather take the risk of death with surgery than the certainty of death without surgery, I had some more calls to make: the senior resident, to come in from home. The OR, who suggested that they had other cases running and perhaps we could wait a couple hours; which returns to the principle that real peritonitis means surgery right now if physically possible, even if that means calling staff in from home. (Perhaps it comes from so many years listening to my father the anesthesiologist making call after call trying to arrange anesthesia and nursing coverage for night and weekend ORs; I haven’t quite adjusted to being the surgeon, the one who declares that it needs to be done, and then leaves it to the OR team to figure out how to make it happen. Not to be authoritarian, but someone has to be the one to say that an emergency is an emergency.) And the attending, one of the older ones, who believes in rattling the juniors at all opportunities. He drilled me with questions (all the labs; the medical history for the last two weeks; recent imaging; why didn’t we do this or that test); and above all, are you really sure that this sick old lady has peritonitis – so sure that you’re going to put her through the risk of an operation. I stood up to him, but by the time he hung up, I was very glad to see the senior resident arriving, and equally impressed by the patient’s physical exam.

She did well – much better than I expected. She’s already extubated, ready to start eating, and looking ten times better than that night (when she was nearly ready to be intubated simply for respiratory distress, by the time we got to the OR).

That was the first time I’ve made a hard call on a patient needing surgery. Deciding that a patient with a moderate small bowel obstruction can have an NG tube and be observed for twelve hours, or that a child with a good story and a good exam has appendicitis, that a patient with a cold, ischemic leg needs intervention, or that someone with a perforated ulcer needs surgery – those aren’t hard; they’re cut and dried. This patient wasn’t straightforward at all. I was the senior surgery person in the hospital, and I dragged everyone in from home, and forced the family to make a difficult decision, based on my clinical assessment. I’m sure this story is not that impressive to any experienced doctors who may be reading, but it was new for me.

And next month I get to do that every single night. . .

« Previous PageNext Page »

Follow

Get every new post delivered to your Inbox.