surgery


Can I remark again how absolutely infuriating I find it, that the surgeons’ lounge here is inside of the men’s locker room? Infuriating, and humiliating by how completely everyone overlooks the fact. This is why you -me, actually; the guys don’t have this problem – can never find most of the attendings, or senior residents, between cases: but the two women attendings, and the female residents, will always be found standing by the OR desk (or wandering the ICUs), because we have nowhere else particular to go.

(And please, now is not the time to discuss my theoretical inconsistencies. I might throw something. . .)

I think I mentioned before that, along with being the insane Christian conservative of the hospital, and being too polite to be a surgeon, the other residents tease me about doing procedures on anything that moves – or doesn’t move, more accurately.

Today I blew my last chance of pleading innocent. Being at loose ends (as seems to be usual for me on this rotation), I was just wandering around the ICUs to see what kind of trouble other people were having, and maybe cheer myself up that I wasn’t having to take care of those problems. I found a couple lines to put in – various people having too many things to do at once, needing to be in the OR, etc, so I volunteered to put in their lines.

The guys found me apparently lost in the MICU, in the middle of a real mess. “What’s up, Alice? Is this your patient?” “No, I’m just putting in a line.” They cracked up, and claimed not to believe my explanation of having a really legitimate reason for being involved.

The best part is, those were some of the hardest lines I’ve done – and they could see that they were hard sticks. I’ve decided to embrace this game. If I can’t be in the OR, placing tricky lines is stressful and satisfying enough that I’m happy to be the one who comes to mind when people want lines done. After all, that’s part of a community general surgeon’s practice.

It’s amazing how much the responsibility for presenting at M&M [morbidity and mortality conference] concentrates the mind. Now I’m not just worried about the patient as a person, and about my role in events; now I’m also trying to avoid having to present a complication/mortality, and then trying to figure out how on earth I’m going to explain this one. So far I can’t come up with anything even halfway presentable; it’s going to be a miserable morning when my turn comes around. No wonder the seniors look so disturbed when complications develop.

Surgery is a great field for a fashion-challenged person such as myself. On any given day, there is one easily-obtainable set of clothes which will fit in perfectly with everyone else and be completely appropriate for any occasion, ranging from early morning rounds to professor rounds to clinic time to the OR to emergencies on the floor or in the ER.

On the rare occasions when more formal attire is required (some professors’ rounds, when giving speeches, etc), this is usually clearly spelled out ahead of time, due to the propensity of both male and female surgery residents to wear scrubs whenever they have not been instructed otherwise.

There was one program which I liked when I interviewed at, but I got a clear indication that it was not for me when one of the residents mentioned that their attendings were so formal, they were required to wear business clothes at all times except when actually in the OR, and had not infrequently found themselves dressed in a tie, running a trauma code. A bolt of lightning could not have been a plainer “stear clear” sign.

Another thing I need to learn to be a real surgeon: When doing an open abdominal case on a patient who’s had practically any previous operations, there are bound to be adhesions to some extent (unless they’re on chronic steroids, in which case you get the prednisone effect – wonderfully smooth going in, and the near-certainty that they won’t heal afterwards). Depending on how many surgeries and where, and the patient’s genetic tendency toward scarring, there will be more or less adhesions, and it will be more or less difficult to get where you’re going.

When dissecting the adhesions apart in order to get to the underlying structures, you have to protect the bowel somehow. Touching the intestines with the bovie (electrocautery) is very much frowned upon, and can lead to all kinds of complications, ranging from post-op abscesses to enterocutaneous fistulas.

There’s a really simple maneuver to help avoid this. You slip your gloved finger under the band of adhesions, separating it from the bowel underneath. Then you bovie on your finger.

The bovie is hot.

This can really hurt.

If you don’t time it just right, you can go right through the glove into your finger.

The good surgeons 1) know how to time it, and 2) care more about protecting the patient than about how hot their fingers get.

I am still a source of frustration to my mentors for two reasons: If I ever have to put my hand under the bovie, I can’t take the heat, and I back off way too soon, which makes it take forever to get anything done (which is too bad, because it’s quite a privilege to be given the responsibility of putting your hand under and guiding where the incisions will be made, and I hate to mess up when an attending lets me do that). Or, when it’s their hand in there, I hit it. Either way, not popular.

I need to do some more surgeries.

Quick note to say how much I’m enjoying Greenfield’s chapter on liver anatomy. This was previously a closed book to me, and whenever anyone started discussing liver anatomy/resection/any surgery coming close to the liver (which unfortunately includes a lot of surgeries), my eyes would glaze over, and I would start gazing at a point in the middle distance, hoping they would get through it before it occurred to them to ask me a question.

No more. I have finally grasped the eight hepatic lobes, and why lobe 1 is in the back, and lobe 7 is off in a corner. This is fairly significant, since most pictures of liver anatomy show the eight lobes split off, as though a 3D animation is about to start, with all kinds of spider-like connections between them. Since there are four flow systems in the liver (arterial, biliary, portal and systemic venous), any map of these branches can get quite flowery. But I could draw it for you now. . .

First time for a while that a surgical textbook has been literally a page-turner. Try it yourself.  ;)

Every morning I make a resolution not to get into a conflict with any attendings for the day. I usually fail by 11am. I don’t know why. I guess I hate this service enough, and am irritated by some of the attendings enough, and wear my feelings on my sleeve enough, that that’s inevitable. I’m trying to help, but trying to help when I’d rather not be in the same unit at all really doesn’t do much good. At least it entertains the rest of the residents and the nurses, watching the fireworks. I just need to not talk in front of the attendings. At all.

I got to assist with a trauma ex-lap (exploratory laparotomy) today. The patient was just sick enough to need it, but stable enough that no one was really panicking. The attending and chief could spare a few seconds to tell me what they were doing. In textbook style, as soon as they opened the peritoneum, blood came pouring out onto the table. They packed all four quadrants with quantities of lap pads – I have no idea how they can ever keep track of how many went in where – until the bleeding was controlled. Then they started in the corner where they knew there were no problems, and proceeded to explore. Between me being there to be lectured and quizzed, the attending being an extremely conscientious character, and the chief being the inquisitive kind who wanted to see everything and visualize every possible maneuver (Kocher, Pringle, etc) while he was there, it was quite educational. And also beneficial to the patient, who did well.

(Kocher maneuver: reflecting the duodenum medially in order to visualize the head of the pancreas. Used in trauma to gain control of the IVC, and in surgical oncology to reach tumors in the pancreas. Pringle maneuver: clamping the porta hepatis (portal vein, hepatic artery, hepatic bile ducts) to get control of devastating hemorrhage from the liver that can’t be controlled with packing alone.)

The chief spent most of the day in the ER (nine patients in two hours on a weekday morning, as though all the old ladies in the city had decided to fall and hit their heads at once, while several un-drunk drivers managed to have serious accidents), and complained that he hadn’t been able to see the unit patients. I, on the other hand, had more than my share of the unit, and would gladly have bailed out of it to share in the chaos in the ER; but we each had to stick to our own responsibilities.

I managed to make a mistake, argue with the attending and the chief about how to fix it, and get myself cursed out in front of what seemed like most of the ICU – a very attentive audience. Good thing I was wearing a surgical mask at the time, or my expressions of dismay and resentment would have been even more transparent, and I would have gotten in even more trouble. It ended well for the patient, at least. I still maintain that my solution would have worked, but in retrospect, arguing with the chief and the attending, at the same time, when I was in the wrong to start with, and they were having a bad day, was not exactly wise. By the end of the day we seemed to be on speaking terms, I with them, and they with me; which I suppose says something about how well we get along together, to be able to have a gigantic fight and still keep going.

Apart from that central explosion, nothing much else happened. I’m fortunately not on call tonight, which is ok with me, because the trauma pager is going off with one unhelmeted motorcycle or ATV accident after another. You may conclude that the weather is quite fine. Tomorrow morning I will have further evidence that young men are fools (for not wearing helmets) and/or sissies. (Because they all scream and cry about nonexistent or minor injuries. No one makes as much noise as the 20-yr-old guy with a broken clavicle and a lot of road rash; a woman the same age with an open tib-fib, or an older man with an open femur, or an elderly lady with 10 broken ribs, will all be much more stoic. I have had no sympathy for young men since the day that one of them had me persuaded he had a broken clavicle, a dozen broken ribs, and a broken femur, from the amount of noise he made; after giving him dilaudid, we got through CT and xray, and found that he had a cracked clavicle, and nothing else. Pfui.) (And I’ve injured myself in sports too, and didn’t scream for more than five minutes, so I’m allowed to talk.)

It was a Saturday night, and I was on the vascular service, so being on call meant I was covering the vascular patients, plus urology, plus plastics. Which can add up to a lot, if the urology attendings have decided to do a couple of radical prostatectemies and urological reconstructions before leaving for the weekend. Or if plastics is on call for traumatic injuries. Fortunately, urology was quiet, and plastics was only on for hand injuries, of which there were none.

So when, around midnight, five or six ATV accidents started coming in in short order, I had time to go help. I had one end of the trauma bay, and I got the third helicopter transport, a young man, fairly alert, with some scalp lacerations, lots of bruises and lacerations everywhere else, and a mangled left leg. ATLS protocol, by the book, didn’t show much of anything – except for that leg. The foot was hanging at a strange ankle, and the foot looked quite pale compared to the other side. No pulses were palpable and he could only wiggle the toes.

The orthopedic resident was moving from one stretcher to another, distributing splints, and making notes for who would get to go to the OR first. He cocked his head at this one. “I’m not getting any pulses here, perhaps you guys should consult vascular.” “It’s ok, I am vascular,” I told him. I had already dug up the hand-held doppler, which is the mainstay of vascular workup in the ER: if you can hear pulses, it’s not too bad; if you can neither feel nor hear the pulses, then the limb is truly ischemic and will be dead within a couple of hours (6 is usually quoted).

The trauma attending finally had time to get to that end of the bay. “This is a pretty bad open fracture. Can anyone feel pulses? Maybe we should consult vascular surgery.” “Yes sir, I am vascular; I was just helping out down here. I think it’s bad, there are no dopplerable pulses, and we’re about to call our attending.”

The situation was fairly textbook: an open fracture with clear distal ischemia. Don’t pass go, don’t collect $200 or any further studies, proceed straight to the OR. Since I had nothing better to do except sleep, I helped move the patient into the OR, and watched the orthopods fit the pieces back together and fasten them in place with an ex-fix (external fixator; like lego outside the leg; it stabilizes fractures, especially contaminated ones, for a couple of days, usually in preparation for definitive internal fixation; they’re cumbersome, and people often try to ignore their presence, but it’s actually easier for the patient if you move the leg by holding the ex-fix, since that won’t make the broken bones rub against each other, which is what really hurts).

Then, since my pager kindly remained silent, I got to help the vascular attending and chief (one of my heroes: smart, and good to work with), who were by this time fairly beat, since it was the fifth emergency case of the weekend. We prepped both legs, and the chief and I harvested the saphenous vein from the uninjured leg through a series of small incisions that we tunneled between to reach the whole vein, while the attending cleaned up around the injury on the other side, and found healthy artery on both sides for the anastomosis. He and the chief each took one end, and attached the saphenous vein to the healthy artery, while I started closing all the incisions on the other side. Ortho had already made the fasciotomies (long ugly slashes through the fascial covering of the four muscle compartments in the calf, necessary to relieve pressure and prevent ischemia after a serious injury or period of ischemia), so all we had to do on the injured side was wrap yards of kerlex and gauze around the entire structure of the ex-fix and our incisions, and we were done.

The poor vascular team still had two more cases to go, and I had to go attend to some urology patients about whom I had received no signout. It made for an incredibly long call day, but that was my favorite night to date: a dramatic, classical injury, which I got to follow from the door through the OR, and then round on for the next few days. Talk about continuity.

Surgery has no room for errors. If they happen, there’s nowhere to hide. You cut the wrong thing in the OR, and everybody knows about it. Even if it’s something as relatively simple as getting into the hernia sac you were trying to get around, everyone knows because you have to call for a suture to repair it with. Anything bigger is even more obvious.

When your patients die, everyone knows that too. What happened to so-and-so? Where’s the patient who was in that room? What’s with the blood and paper all over the floor? Why’s your attending so gloomy today (in fact why is the entire service colored grey)?

You also can’t hide in the sense of withdrawing from the life of the hospital. Just because one person died, there are still a dozen others needing help, even others with the same problem. That’s what’s really getting to me right now. One person died, and there’s another patient with an extremely similar problem, whom we simply have to operate on. It would be irresponsible not to – and yet it feels irresponsible to go ahead. Statistics say there was a 1% mortality rate, and that patient bought it – so really the next hundred ought to do great; but I don’t want us to do that same operation again so soon. It seems like tempting fate. I can tell the attending doesn’t want to, either. For a guy who doesn’t talk much anyway, the main way he shows emotion is by talking even less, and more inaudibly than usual (which is harder to deal with than another attending cursing and swearing). But he has to take the case. There’s no one else who can do it, and the other patient can’t wait.

I guess it would be more accurate to say there’s no room for denial. Errors, and inevitable complications, occur. The big thing is not to hide from them. You can’t be so insistent that there were no technical errors that you refuse to go back to the OR for postop bleeding. You can’t ignore an enterotomy and hope it goes away without you stitching it up, and admitting to yourself and the scrub and the circulator that something slipped. You can’t pretend that the patient didn’t die, and that if you don’t even think about a patient with that disease for a month, it will somehow undo their death.

(Which is why I hate euphemisms, especially at M&M: “The patient CTB (ceased to breathe).” Come on guys, we’re surgeons. The patient died, is what they did. They’re dead. That’s why we’re discussing it.)

I hate it when my patients die. Somehow it feels worse when I wasn’t there at the time, as though in addition to generally having let them die, I also failed to be with them when it mattered. At least I didn’t have to see the family. . . I can’t even think about them. I can say to myself, the person I was talking to yesterday is dead and gone. . . but I can’t bring myself to even imagine the family, how they received the news . . .

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