surgery


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. . .

Back in the OR at my own hospital, I realized several other things I’d been subconsciously missing at the children’s hospital: besides a mutual recognition with the techs, nurses, and anesthesiologists, and material things like scrub sinks working the way they should, trash bins sitting where they should, and light handles that fit the way they should, I’d missed the attendings caring what I did. At the other hospital, I was very much a  migrant: they put up with me for six weeks, and now they’ll never see or hear of me again. As long as they kept me from doing any positive harm in that time, they could care less whether I learned to operate well. Here, the attendings know they’re stuck with me for several years, and I think even beyond that pragmatism they’re committed enough to teaching that they care about my learning.

This manifested itself in the attending criticizing nearly every move I made for two hours. The minute we started draping, it suddenly hit me that this was a much more complex operation than the appendectomies I’d been doing for the last several weeks, and I nearly froze. It took an effort to do simple things, things this attending long since expected me to do quickly and semi-smoothly. Him telling me to loosen up didn’t really help, but after ten or fifteen minutes I started to get in the swing of things. Back to the usual pattern of him stopping every five or ten minutes to explain why my actions were completely counterproductive, stupid, harmful, or simply inelegant.

That may sound like a complaint, but really it was good (and even better when done with) to have the attending take the time to talk about technique. This attending likes to repeat, “You should do every case as if the patient was your own mother.” Personally I find the metaphor a little disturbing, but he’s teaching professional attention to detail at all times.

At the end, I found that in the middle of all the stress and criticism, he was actually letting me do more than he ever had before – which was why he found so many things to teach about.

And that leads to a last humbling conclusion. I have so much more to learn about surgery before I will even begin to be a surgeon. Now I begin to get the hang of where an operation needs to go, what the next step needs to be; but on my own, I go so slowly, hunting and pecking my way through. I don’t have the confidence in my plan to jump in, and push, cut, tear, burn things to get where I’m going. And that’s what it is to operate: to know so thoroughly where you are, and what needs to be done, that you can cut without hesitating.

One of the medical students, one week in to his surgical rotation, confided after rounds that he’d been shocked and disconcerted by the attending swearing copiously at my presentation about the first two patients, who’d had some significant setbacks overnight. Myself, I had simply been reassured that he was cursing at life in general and some consultants’ practices in particular, and was not blaming me for any of it; and as long as the cursing wasn’t directed at me, I wasn’t too upset. The effect of a year and half with surgeons, I guess.

Ok, I’m back online. This rotation is nearly over, which is a good thing, because honestly I’m more depressed, miserable, and angry than I’ve been in residency so far (except maybe on trauma; and that was made more tolerable by having friends around, residents and nurses I knew and trusted). Now I’m trying to figure out what to say when I get back “home,” because several of the residents were teasing me that I’m so optimistic, but the peds rotation would destroy me. They were mostly right; I’m just hoping it’s not permanent; and I don’t want to admit it to them. There were three rotations of second year that I knew would be absolutely horrible; one down (almost), two to go.

Anyway, I’ve been remembering the things that made me go into surgery in the first place (a decision that I’m not up to defending right now, just hoping I’ll feel better about it once I get away from this place). One particular story I remember because at this hospital we had a child develop a wound dehiscence after an abdominal surgery. Supposed to be pretty rare in kids, and the M&M on the subject was protracted, to say the least. A dehiscence is when the fascia (not just the skin) comes upon. There are two main reasons: you didn’t sew it properly to start with, or the patient’s tissue, for various reasons (debilitation, radiation, steroids, infection, to name a few), is so weak that it simply doesn’t hold even the best suturing.

I was on call on ob/gyn, and in between the deliveries and an ectopic pregnancy case, the team got called about a patient in the ER. She’d had an abdominal hysterectomy about a week previously, and had gone home shortly afterwards, apparently healing well. She dehisced at home, fortunately only to a minor degree, and came in to the hospital. As a medical student, of course I was fascinated, and tagged along the whole way; but I was also frustrated by the OBs’ response. The intern went and looked, and paged the senior; he went and looked, and called the attending. She didn’t believe him, and went to look too. At that point they agreed that they supposed it was a dehiscence, and called the surgeons to ask for advice.

I’ll never forget the surgery intern (who was after all tall, handsome, clever, and only not cocky because he was smart enough to warrant his own confidence). He strolled in, looked at the wound briefly, and remarked, “Yes, it is dehisced, sure enough. You’re taking her to the OR, right? You don’t need us for anything, do you?” The OB attending agreed that this was her plan, but insisted that the intern bring his senior, and even the surgery attending, in to look at things in the OR. Her explanation also sticks in my mind: “I never saw anything like this, even in residency. I’m not sure what to do with it. And maybe we ought to run the bowel [surgical speak for starting at one end of the small intestine and looking carefully till you get to the other end, to make sure there are no injuries or other anormalities], and I forget how to do that.” So the attending surgeon, being dragged out of a sound sleep (they were required to take in-house call, but counted on the seniors to shield them from any disturbance except a trauma requiring a laparotomy), came in to the OR and explained to the OBs that when the fascia comes apart – you should sew it together again. The end. And if you want to run the bowel – you start . . . at one end. . . and proceed . . . to the other end.

I’m not trying to make fun of the OBs, because they were overall good at what they did (that attending was one of the weakest), and I understand that dehiscences would be much rarer in a population of relatively healthy women (overall younger than the general surgery population) having elective hysterectomies. But to a medical student, it was noteworthy. Even then, several months before I did my surgery rotation, and got swept off my feet, I started to think that I’d rather be sure of the basics.

I still hate this rotation. But I expect I would have found at least one occasion to be equally miserable if I were doing ob/gyn, as I originally planned.

I ought to tell another story, where the joke is on us. We had a pregnant woman staying with her sick child at the hospital. One evening, the nurses called the fellow in a bit of excitement: the mother was having contractions, with increasing frequency. He ran upstairs, and became quite excited himself, and eventually with great commotion hustled the lady off to an adult hospital with an OB ward. Myself, I regarded it as less of a problem. First, unlike the fellow, I’d known she was pregnant prior to that night (just by looking; I guess he didn’t notice). Secondly, I considered that with her contractions still 8-10 minutes apart, she was unlikely to deliver within half an hour, which was plenty of time to arrange transfer (second pregnancy; maybe I was being too pessimistic). Thirdly, I privately thought it would tremendous if we did have to assist with the delivery after all. Of course, that was the thought that was really upsetting the fellow.

By the end of the last call, I was having fun. I’d jokingly protested at the ER residents every time they called me with appendicitis in a teenager for the last several days (for surgery residents’ purposes, we only get credit for ‘pediatric’ cases if the patient is under 12; so, although all the surrounding surgeons and anesthesiologists refuse to touch a patient under 16, often 18, and send all the teenagers with appendicitis to the children’s hospital, my paperwork doesn’t benefit unless some actual children have appendicitis), and nearly had them believing that I had single-handedly effected a policy change, ie surgery residents would no longer come to see teenagers.

Finally, they called me about a nine year old. Only one day’s worth of symptoms. I wasn’t expecting much, hearing the story from the ER, but when I touched the child, she had peritonitis.

One thing I have learned from this rotation is the amazing range of variation in appendicitis. Some children will show up after one day and be perforated; others will show up after a week, and still be well enough that you can’t be sure they have it. Some will have a normal white count, others will be in the 20s or higher. Some fevers, some not; some throwing up, some not. The physical exam seems to be the most reliable indicator (short of a CT, and the attendings at this hospital are great ones for discarding that security blanket), but even then there will be a lot of discussion: the ER doctors, the junior residents, the fellows, the surgery attendings – all will have a different impression of just how bad the child is. Sometimes I call it, the fellow says no, and a CT or an overnight observation proves me right; more often, the other way round. Sometimes the attending decides to go to the OR, despite nobody else on the team being impressed, and they’re right.

Last night, I knew the girl had appendicitis. It felt exactly right; the white count was up, but not so high as to look viral; low grade fever, again not high enough to point to a virus. Everyone else was busy (or sleeping; hard to tell which when they don’t answer pages), and I couldn’t get any seniors to confirm my conclusion. (Another frustrating thing about this hospital is the lack of confidence placed in the junior residents. My place on the team is interchangeable with an intern. At my own hospital, I can take all the surgery calls all night, run the surgery ICUs, and book multiple ORs by myself; the attendings take my word for it. The pressure is high, but I’ve gotten used to it; I expect it. Here, I can swear up and down that a child needs to be in the OR (or that they’re ok and should be fed), and almost no one will let me act on my diagnoses.) So after an hour I said forget about fellows and attendings; admitted the child, started antibiotics, and called the OR. I even gave her a good dose of morphine, and crossed my fingers that the oft-repeated adage that narcotics can’t mask peritonitis would come through for me.

It did. When a fellow finally got around to see the patient, he was adequately impressed, and confirmed my plans. Then I got to do the case myself. The attending was kidding me the whole way in: “You think this kid has it? She really has it? What makes you think that? Fever? That’s nothing. What’s the white count? Don’t you think that’s a little high? Only had symptoms for one day? Come on; she gets on operation after one day?” So of course that made it extra fun when we found purulent fluid in the pelvis. The attending was one of the nice ones, who let me do every single step even when it took a minute longer. (Perhaps nice is not the word for it. Really it’s a matter of confidence: he knew he was good enough that he could afford to let me go slowly. It’s the attendings who don’t have the skills themselves, who aren’t confident enough to push the residents forward.)

After all, it was nothing much, an everyday occurrence: a child with appendicitis, an uneventful surgery. But I was there the whole way through, and I felt as though I was managing it myself. Very satisfying.

One of the ER bloggers a while back mentioned something about “knowing how to talk to surgeons on the phone,” and I didn’t know what he was talking about. I do now.

There is nothing more annoying, in the middle of the night (or a busy day), than to get an ER doctor trying to give you a five-minute presentation on a patient. I really do not care what time the patient went to the outside hospital, or how exactly they got transferred here; unless the creatinine is 3, I don’t care what the chemistry shows; unless you have a positive urinalysis, and are apologizing for calling me anyway, I don’t care what the urinalysis showed (yes, sterile pyuria – white cells and no bacteria – can help confirm a diagnosis of appendicitis; on the phone, I still don’t care); unless you got a CT scan without asking us (which would be ok, if it shows appendicitis), I don’t care if you got xrays on a patient whom you think has appendicitis; I also do not care which ADHD and asthma meds the kid is on (unless they include high-dose oral steroids); I don’t care whether (when calling for appendicitis), you think the abdomen is distended or not, or whether Rovsing’s sign is positive or negative. All I really want to know is, what room is the patient in, and a name or medical record number, so I can track them down when they change rooms. Apart from that, you can be as impressed as you like by the abdominal exam; you could think they have peritonitis. I don’t care, I have to touch it for myself, and until you give me a room number I can’t do that! (At my own hospital, about half the ER residents, I would care what they think about whether the patient is truly surgical or not; here, I haven’t had time to learn to trust the ER staff, so. . . I don’t care whether they think there’s rebound or not.)

Bottom line: you called the surgeons because you want us to touch the patient. So give me the location of the pain, and the location of the patient, and stop talking. The best calls are from the male PAs, who usually are not too chatty: name, age, medical record number, chief complaint, white count, “I think it’s real” or “I’m not sure, just come see.” End of conversation.

Unfortunately, I don’t know a polite way to say that to attendings, fellows, or residents I don’t know (ie the entire ER staff at the children’s hospital),  so I get very frustrated at night.

I’m also puzzled by this: the surgery resident’s ethos puts a lot of stock in instant response: if you call me with a consult, I will be there in five minutes if I’m not doing something important; and if I’m in the OR, I will be there five minutes after the end of the case. (And if the nurses call, I will address their concern immediately if it’s urgent, or as soon as it comes up on my triage list otherwise.) In fact, sometimes it’s the only thing that keeps me going at night: I can’t think straight, I’m not sure which elevator goes where, or what floor I’m on or am trying to get to, but I will be in the ER two minutes after getting called. So why do the ER people call, then act surprised when I show up? Or why do the general peds teams call us at night with a consult “for you to see in the morning”? If you call me now, I will see it now; I will not save work for the morning. If you don’t want the patient and family woken up at 11pm, don’t call me at 11pm. (I know some residents aren’t like this, but it’s not just me, because I learned this from the chiefs getting angry at me if I wasn’t ready to report on a consult within ten minutes of getting the call, or the first time they heard about it, whichever came sooner.)

Ok, I’ll stop being grouchy now. I hope I have any personality left at all when I get away from this hospital.

The OR and ICU staff are coming to the conclusion that I’m crazy. They can’t tell why else I would spend the day with a stupid grin on my face, when all they can see is that I have some of the sickest patients in the ICU, the worst cases on the schedule, get no help with scutwork from the more senior residents (some seniors help, some don’t; mine don’t), and have attendings whose form of praise (I’ve decided) is to come up with more unique phrases to explain how incompetent I am. (I know this because he was doing it today while I was doing a simple job perfectly, so I think he really meant it was nice to have me around so he could say things like that.)

It seems a little embarassing to keep explaining to everyone I see that I’ve been doing more surgery in the last few weeks than ever before, and more complex. After all, it’s hard to admit even to the OR nurses that this is my first time at nearly all these procedures. I’m perfectly happy to have an OR schedule crowded with hard cases, because that means some good ones trickle down to me. I don’t mind staying late nearly every night, because it means I’ve been in the OR most of the day, and have to stay late to catch up on people.

The sick ICU patients are not so great, but at least they’re all still alive, which is more than we expected of some of them. And them being sick is not my fault, not by the remotest stretch of anyone’s imagination, so I can take care of them without feeling guilty for them being in the ICU. (As in, if I had paid more attention, would I have noticed some miniscule fact that would have made a difference in their care earlier.)

The intern summed up the day’s events nicely: “When the intern gets paged to the OR stat, you know it’s never because things are going well.” [since the only thing one would want an intern for stat is to hold retractors in a case that's getting out of control]

Similarly, when the junior resident repeatedly scrubs major cases, it’s not because anyone intended it that way, it’s because all the senior people are tied up elsewhere. But it didn’t stop me from enjoying the cases tremendously.

Posting has been a little light due to a recent transplant marathon: one transplant after another, starting in the afternoon, and concluding the next morning. The best summary would be to say, that after doing so many of one procedure in a row, I knew the steps in my sleep – which was good, because that was what it was close to by the end. . . I still wasn’t able to satisfy the attending, who seemed to want to know why, twelve hours after he’d first told me I needed to improve a point of technique, it still hadn’t been corrected. (Saying, Sorry, right now I’m lucky to be standing up straight, and doing something at least functional with the instruments, can’t think straight enough to change habits right now, did not seem like a good idea.) (I sent the poor medical student to bed some time after midnight; he also seemed to find that irrational, but neither of us had enough energy to discuss it in detail.)

I got my fill of “continuity of care:” admit one patient, scribble some pre-admission orders (stat labs and induction immunosuppression) for the next one, run down and do the back-table on one kidney, go meet and examine the second patient, do the first case, write pre-admission orders for the third, back-table the second kidney, go check that the first one is still making urine, look at his chest x-ray, and continue. . . Then, the day after, even though the attending and I rounded before leaving the hospital, so I technically had handed over coverage of my patients to an on-call intern, neither I nor the nurses felt like leaving the intern in charge. If I didn’t wake up every hour to call and check on someone, they were paging me, or else had stumped the intern and he was calling to ask me. . . Eventually I gave up on sleeping and tried to get some chores done instead. I hate that feeling of waking up, and not being able to remember which nurse I had intended to talk to this time, or whether the fluid bolus I’m thinking about is something that has already happened, or that I still need to order. I keep intending to take a paper with me and write notes, but around the time that the difference between am and pm disappears, the coordination required to get a paper and pen in the same place also drops off. The significance of low urine output, however, sticks around.

It’s taken me 16 months of residency to find out what surgery as a profession is really like. I need to figure out who in the hospital has coffee available at midnight before trying that one again. Otherwise, give it another day or two, and I’m up for it.

For the first time, I was the one called in in the middle of the night for a case. On one hand, it threw off my schedule a lot more than I’d expected. I’ve always told myself that getting up at night would be ok, because there’s such an adrenalin rush in the OR that I would wake up and be fine. We were partway through the case before I felt anything like that. I guess the excitement was more associated with novelty than I realized, and now that scrubbing on a case as the primary resident is becoming more routine, I can’t count on that energy for the middle of the night.

On the other hand, I feel like more of a surgeon than I ever have before, and it’s wonderful. A lot of it is due to the great attending I’ve been working with. He lets the resident, even as junior as me, have the surgeon’s side of the table, and make a lot of small decisions about how to proceed next. He doesn’t criticize the whole time, which makes it so much easier to work; I know he’ll only say something when he really means it. He makes me really a part of the case – dissecting difficult spots, making some decisions about sizing the vascular anastomoses, sewing the anastomoses, and tying important knots in deep corners. (The ones that I have too much of a tendency to break. . . but not last night.) I think I’m actually becoming slightly competent at some of this; not quite second nature yet, but it will be soon. I can start to think about the whole course of the operation, and the strategy, rather than having to concentrate completely on just how to hold my hand next.

So what if the price is losing a night’s sleep. . . it’s worth it.

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