surgery


One of the things I love about medicine, and especially surgery, is the potential for drama. Everything seemed to be cruising along just fine – although it was the kind of just fine where everyone is saying under their breath, “How come this patient is doing so good? The surgery was so big, I can’t believe he looks this good; when does something bad happen?” And then it did. I was just strolling by, and peeked in to see the nurse about to page me, and the patient tachycardic, tachypneic, hypotensive, and hypoxic. (Medicalese for fast heart rate, breathing fast, low blood pressure, and low oxygen.)

On the other hand, I’m realizing again (as I do about every two months) that I spend my life around sick people. We were talking about one of our patients being particularly crazy, and I thought, When was the last time I talked to a normal person? Yes, most hospital patients are slightly strange in their conversation – they’re in the hospital! And although usually easier to converse with, residents are not exactly normal people either. I tell myself that statistically speaking the majority of the world’s population is neither hospitalized nor medical personnel; but I have a hard time remembering what they’re like to talk to. (I should be doing peds – all those well-child checks. . . Hmm; maybe stick to sick people.)

I guess what’s really getting to me is that I’m not operating a whole lot this month. Maybe I had rose-colored glasses last year, looking at the juniors, but I expected to operate more. I don’t think I can stand to wait another two years till I get to be a senior resident in order to operate on a semi-regular basis.

My technical skills are poor. I know that. But if I got in the OR more than once a week, I might get better. As it is, I can see myself improving through an operation, or if I ever get two in a day, the second one is always smoother. But then there are another five or six days before I get at it again, and I forget what I learned.

So I’m snapping at the intern, and I can’t tell whether it’s just me taking my frustrations out on him, whether the fact that I still seem to be doing all the work on the team is purely a result of my poor management/delegation skills, or whether he really is as unhelpful as I imagine him to be. . .

I had it hammered into me last year that the resident doesn’t ask for OR time, doesn’t ask for anything even when scrubbed in; you do what the chief or the attending tells you to, always, everywhere. . . so I don’t think it would do any good to ask; but my deferred-gratification capacities are getting pretty strained. I thought I only had to get through internship and life would get better; it hasn’t really, and the prospect of doing scutwork for another two years in order to earn the chance to live my dream is extremely discouraging. Jacob served seven years for Rachel, I tell myself; somehow that doesn’t really help, can’t imagine why not.

I guess that’s why I’m jabbering about work hours; somehow I imagine that if we were allowed to work longer, I’d get to operate more. That’s probably completely unrealistic. It’s still ridiculous that, in addition to trying to take care of my patients properly and get out of the hospital sometime before 9pm (I’m not completely insane, I do like to get home in the evenings) I also have to worry about finding a time clock to swipe out on, and remembering whether, although I’m still at the hospital, I’ve marked myself out, or not yet.

I told the medical students, you know you have to do surgery if you get homesick for the OR when you go on to a different rotation. It’s infuriating to have it within reach, within eyesight, and not be able to get there.

We’re revisiting the subject of restricted duty hours. As Aggravated DocSurg comments in his humor-laced sarcasm, any sane person would be happy to be working less; so I must not be sane, to be a resident arguing for longer hours. But I think the “old fogies” have a point; and we ought to listen to them before it’s too late to turn this around.

This essay by a neurosurgeon (beyond being an extraordinary demonstration of how to claim to be superhuman, without being arrogant) has applications for all surgeons. Dr. Vates argues that neurosurgeons are unique because they deal with the only non-replaceable, non-repairable part of the human body, which is true; and that they are a breed apart, and that’s true as well. But he also suggests that if you think a surgeon’s ability to perform complex or delicate operations is impaired by fatigue, the solution ought to be to get really good at the procedure, so as to have room to work with when you’re tired. He repeats the line, which ought to be a self-evident truism, but apparently doesn’t compute for the folks at ACGME, that there are no hour restrictions in private practice, and that if we’re concerned about fatigue impairing judgment, that too should be practiced first under supervision.

Apparently some idiots are seriously proposing limiting the work week even farther, to 56 or 48 hours. I object. 80hrs is barely enough now; frequent readers of my blog will have recognized that I regard this as a rule made to be broken. If they cut it down to 56, they will have to extend the length of the residencies; right now, most people are 30 by the time they finish residency, let alone non-traditional students. Lifestyle may not be an issue under that regime, but paying back debts in time to have some money saved for retirement will be.

So I highly approve of Dr. Vates’ solution: The ACS needs to take its toys and leave, ie opt out of the ACGME, and set up its own standards for residency accreditation. Of course, since ACGME recognition is a prerequisite for Medicare to pay for anything, and for board eligibility, this is the kind of thing that would have to be orchestrated with 100% participation, essentially a boycott of the ACGME by the surgical specialties. I’m looking to see where I can sign a petition to that effect. . .

I love hernias. Repairing an inguinal hernia seems to be an activity most akin to juggling several balls while standing on your head facing backwards. In other words, after doing it a couple of times, and reading three different textbooks prior to the most recent effort, I still have only a minimal understanding of which piece went where and why.

There are four or five main layers to the abdominal wall, I get that much: skin, fat, Camper’s fascia, Scarpa’s fascia; then you get the external oblique muscle – but down that far, there’s only the external oblique aponeurosis, which runs into everything else; and the internal oblique, and its aponeurosis; and the transversus abdominis, which blends into stuff, and the transversalis fascia; plus the preperitoneal space/fat, and the peritoneum itself. Now if all that would just lie flat, it would be enough trouble. But then it bends, apparently through a warp in the space-time continuum, and you get the inguinal ligament, Cooper’s ligament, the external inguinal ring, the internal inguinal ring (if only I had One ring to bind them all!), and the cremaster fascia. I keep reading the textbooks, and turning them around and around trying to figure out what Cooper’s ligament is and how it relates to all the rest of this stuff, and I still can’t see it. As a sign of how lost I am, when they illustrate this anatomy unilaterally, they usually don’t label left/right, up/down, and I can’t even tell where we’re at, or whether we’re looking from the inside out, or the outside in, let alone where things connect to.

So it’s a good thing I’ve been doing this with one of the quiet attendings. He doesn’t say much of anything unless you’re recklessly out of place (for instance, being so awe-struck by the sight of the hernia suddenly dropping back through the hole – a hole, any hole - actually the internal ring - back into the peritoneal cavity, that you completely forget how to tie knots, and start tying them a couple inches into the air, when he mildly observes that maintaining tension on the suture tends to make for a tighter knot, and thus a more durable repair). (That was last time, this time I got a grip on myself, and the suture, too.) Anyway, although I have no doubt that I’m making all kinds of wild gestures through my lack of comprehension of where we are or what we’re going to do next, he hasn’t said anything, at least to me.

I feel like this is fascinating enough to keep doing straight for a couple of months at least; maybe by then I’d figure out which way is in and which way is out.

(In other news, when the ICU nurse warned me that the critical care attending was doing things with my patient, and likely to go farther, I tracked him down, and remarked in a polite manner that I’d been talking to the patient’s family. He informed me in a rather high-handed tone of his intentions to completely manage my patient in the future. I said no, now that he mentioned it, the patient was on my attending’s service, and the surgical team felt quite comfortable taking care of the foreseeable future. He did a double take, and I stuck my chin out and said we could handle it quite nicely, thank you. It felt good to get that out in the open, and certainly he hasn’t been seen or heard from since. Unfortunately it didn’t improve my patient at all. I wish I could ward off the angel of death as easily as that.)

New attending syndrome. It’s the well-known phenomonen of attendings fresh out of residency being a little hesitant to diagnose anything during the month of July.

Mostly you can work around it, but when a radiologist comes down with it, things start going haywire.

There’s a new radiologist on staff, and I keep running into her and her readings. So far they’ve been exemplars of non-specificity, but today was the worst. I got called about a patient in the ER, a boy with abdominal pain. “The radiologist says he could have perforated diverticulitis, please come and see.” Now a teenager shouldn’t have diverticulosis, let alone diverticulitis, let alone perforated. So I looked at the scan, and I couldn’t really make out what the radiologist was worried about, but hey, I’ve been not-an-intern for two weeks, and this is an attending radiologist, so I’d better be careful. I went and saw the patient. He was sore, but not too bad. In fact, he and his father seemed more scared by what the ER doctors had told them about the CT reading than about his actual symptoms.

I looked at the scan and I looked at the scan, and all I got was more puzzled. Finally I went and told my attending that the patient was tender, but not too extremely so, but I was concerned because we had an official dictated and signed report saying possible perforated diverticulitis vs. small bowel obstruction due to Meckel’s diverticulum. He listened to me arguing back and forth with myself, and came to see the patient. He spent a long time calming them down, but when we finally got outside of the room he wasn’t exactly pleased. “That radiologist! What is she reading it like that for? A third-year medical student could tell there’s no diverticulitis. In fact, there’s no inflammation of any kind whatsoever!”

So now I feel like an idiot. I knew the patient wasn’t sick, and I knew there was nothing wrong with the scan, but I let the radiologist talk me into miscalling it, and presenting it to the attending as something concerning. I’ve learned not to trust the radiology residents too far, and now I’m afraid I have to learn not to trust the radiologists much at all (except for three, who are nearly infallible, and all the attending surgeons take their word as gospel). Which scares me more than anything, because I don’t think I’m good at reading CT scans, and clearly I need to be a lot better.

I’ve discovered something extremely useful that the medical doctors do.

I hate walking into patients’ rooms (or into an office encounter), introducing myself for the first time, and within the next ten to fifteen minutes trying to familiarize a patient with an operation enough for them to consent to it. It feels like such an imposition – Hi, I’m Alice, you have cholecystitis, you need to have your gallbladder taken out, we have an OR slot available tomorrow morning, the risks include death, heart attack, stroke, damage to your liver/intestines/bile ducts, bleeding, and infection, please sign this paper. That is really what I say, except more smoothly, and spread out over fifteen minutes. Or, Hi, I’m Alice, your father really is not getting off the ventilator any time soon, he needs a trach and a feeding tube, he can fit into the schedule tomorrow afternoon, please sign this paper. Or, Hi, I’m Alice, I regret to say that your increasing abdominal pain is due to an obstructive colon cancer, you need to have surgery, you’re first on the list for the morning, please sign this paper.

That’s how it happens, because we try not to drag our feet about inpatients. If they’re inhouse, and they need surgery, we’ll do it within the next day or two. And I simply don’t have the time to walk by the room three times in the next 24 hours, to give the patient time to think about it, and then answer questions, and then get the consent signed. The attending will come around, too, but I’m the one who has to get the paperwork in order.

So the medicine guys are great, because they get the patients and families accustomed to the idea of having an operation, and give them some time to come to terms with it, between when it first comes up, and when we arrive to talk about it. Ok, maybe they could stand to check some coagulation labs for patients on coumadin when they call us for an urgent problem, but there’s a limit to how much surgical thinking you can ask from nonsurgeons. Maybe the patients end up with the strangest ideas about how the operation proceeds, or what they can expect afterwards, but I daresay the majority of those miscommunications come from their ears, not from the medical doctors. It is nice to get into the room, introduce myself as a surgical resident, and have the patient say, “Oh yes, they told me I need to have my gallbladder out, my children agree, let’s get it over with, where do I sign?” Sometimes I regret having the wind taken out of my sails, since the patients often don’t want to listen to my speech about the chances of recurring incidents if they leave the gallbladder in, and the possibility of nonsurgical treatment, but I can’t exactly argue about that.

Not much going on these days. The medical students are fun. They’re so incredibly young and naive and eager to please. It’s a great responsibility, to feel that we’re responsible for their first experience of clinical medicine, their first understanding of how to deal with real patients and function as part of a real team. I’m afraid we’re rather a dysfunctional bunch, this month, and I hope it doesn’t teach them too badly.

I’m not happy about the case distribution, but I’m telling myself that all the cases belong to the chief, absolutely; if he decides to let me do any, it’s a gift, not a desert. I knew that last year, because I made myself have no expectation of doing any cases at all; then I was purely grateful if the chief threw me one. I need to hold on to the same attitude this year: if the chief lets me operate, it’s a gift. I wish it weren’t that way, but that’s how the chief sees it, so I’d better fall in line.

It’s actually still a little funny to me, how little say the attendings have, openly, about which resident comes to which of their cases. They make general rules – no interns or second years in cases of a certain complexity – but beyond that, they don’t say anything, even about the residents they like the least. The chiefs control who goes where, even to the point that some chiefs can send junior residents into big cases if they want to. My chief this month is not the kind to do that; he’ll go recruiting residents way beyond our service to cover cases, if he thinks the case is too big for me, and he won’t let me operate at all unless we have two rooms running constantly. I don’t appreciate that, but it’s July, and I’m sure in a year or two I’ll be horrified to see young second years doing anything like good cases.

The MICU was paying me back today. I got no less than seven insane consults from them today, three within half an hour in the morning, and four within half an hour in the afternoon. If they had even had a reasonable explanation for why they were consulting us, it would have been better, instead of things like, “we got this scan for (insert completely wild idea, the scan wouldn’t prove it, and why on earth were you looking for that zebra anyway), and look, there was a bowel obstruction.” That was from one of my favorite of the new class of medicine interns, so I explained as politely as I could that since the patient was completely comfortable, much more interested in getting me to adjust the tv than in discussing his nonexistent abdominal pain, completely nontoxic on exam, and his labs didn’t show any abnormalities, the chances of my attending deciding to operate based on that scan were pretty much nil.

Then there was one of the usual “the patient is septic and going into multi-organ system failure, consult surgery,” with, you will be pleased to hear, hypotension and renal failure being treated with three pressors, no fluids. I tried on that one, but I figured after pointing it out to the team three times, there was nothing more I could say about the iv fluids.

And a couple of “every other surgeon in the hospital has refused to do a feeding tube on this patient, claiming that it’s either unethical or too dangerous, maybe your attending will feel differently.” Um, yeah, when my attending gets out of the OR at 6pm today, and before he starts his eight-hour case tomorrow morning, I’m sure he’ll be thrilled to consider that one. I barely got him to listen to the other consults (after I introduced them with the remark that they didn’t call for action by us).

Somehow, I still managed to feel stressed out, because all the patients we were consulted on were indeed critically ill, and after spending a month in the trauma ICU, I still feel a reflexive urge to try to fix ICU patients, even when they’re not mine, not my problem, nothing I can do for them; so it takes me too long to get through the chart and decide for sure that there’s nothing the surgeons can add to their care. Plus the floor nurses paging me all day: “Are you going to send this patient home when he gets back from the test?” “Well, I have to see him after the test, and then I’ll be able to say for sure.” “Ok, but are you going to send him home?” And the floor medicine residents: “Are you going to do surgery on this patient?” “I don’t know, I have to ask my attending, he’s in the OR, he’s kind of busy.” One hour later: “Are you going to do surgery on this patient?” “I don’t know, my attending is still in the OR, and I haven’t gone by to ask him for the third time today. How about if I call you?” I know, they were trying to clean their list, and I do the same to them by turns (“Are you going to discharge this patient? Please are you going to discharge this patient soon?”)

I got to do my first transplant today.

More precisely, I assisted the attending for the first time today; but I have high hopes of getting to do more of the procedure later on. I really didn’t want to ask for anything more; I was still figuring out the anatomy (well, ok, so the external iliac artery and vein are not that complicated; but the way that the donor artery, vein, and ureter fit in is), and I don’t have much experience sewing blood vessels yet. So I’m content to wait through a couple more of these till he feels like letting me do some of the work.

The transplant attending, as I’ve mentioned before, is completely dedicated to his work, and is extremely hyper when there’s a transplant in the air. He haunts the OR, pacing back and forth, waiting for his room to be ready, calling the coordinators to check on the exact location of the organ in transit. He greets the patient, hugs them, asks if they’re all ready, or have any last-minute questions. He helps position the patient, helps anesthesia put the lines in (ok, so I’m not sure anesthesia wanted any help, but they got some), helps put the foley in, helps arrange the blankets, all the while commenting, “transplant means paying attention to details, Alice; you have to check on everything.”

Then we’re scrubbed in, and the noise level drops off. Everything has to be just so for him, but he has a reason for all of it, so I just do my best to adjust to the way he wants things. No extraneous movements. No unnecessary tension on anything, and above all on the donor tissues. Stay in the bloodless plane between tissue layers; watch the muscles split apart, the artery and vein separate off of each other. Tie countless knots onto nearly-invisible branches off the artery and vein, which will bleed all over the field after the anastomosis if we don’t get them now (“you’re tying better now than when we first met, Alice”). And then the nerve-wracking, painstaking business of matching the veins together, placing the stitches, sewing down; repeat for the artery. The ultimate test: “we’re about to take off the clamps, anesthesia, you all set? all the meds in? the pressure is good? here we go. . .” And the dead-white kidney turns in a split second to a beautiful pink, and you can feel the blood pulsing through if you just lay your finger against the capsule. Watch, and the urine comes dribbling out the ureter. Success! Then the last steps, catching all the little bleeding spots and sewing them shut, patching the ureter onto the bladder, tucking the whole thing into that artificial space at the edge of the pelvis, and watching as you close the muscles to make sure the pulse stays strong, nothing kinks.

I love the sewing and tying, the part where I got to help the most. When I read him right, and had the sutures ready to throw down the minute he had the right-angle clamp where he wanted it, it was beautiful, like a miniature dance. I can’t wait to do this some more, so I get better at predicting the next step, and can do more to smooth things along.

At last, everything closed, we got ready to move the patient off the OR table. The foley bag was already filling up with pale urine, the first that patient had made in years, and it was the most beautiful thing in the world. We changed that patient’s life. We, and the family who donated the kidney. (I didn’t ask how the donor died; I knew it was a young person, and I didn’t want to think about it.)

Dr. Drackman must be the most irreverent writer extant in the blogosphere, and I know I am going to get in trouble with someone for saying this, but I can’t help linking admiringly to this story. Read it for yourself, I don’t want to give away the punchline.

. . . ok, got it?

That kind of thing (free air in a MICU patient diagnosed on chest xray taken for line placement) is the reason I’ve started to make a point of checking the abdomen and the feet of every patient I see, whether surgical or medical, regardless of the reason I’m there. Consultation for thyroid mass? We’ll include an abdominal exam to rule out masses or rigidity, and a pedal exam to make sure the pulses are palpable. I’ve seen too many patients with acute cholecystitis diagnosed after they spent three days in the hospital getting a negative cardiac workup, or calls from the MICU for “a cold foot that we just noticed this morning,” but no one, neither nurses nor residents, can certify when was the last time they actually looked at the feet and noticed them to be normal – maybe not even on admission. (And yes, we complain when the ER calls us for biliary symptoms in a patient with enough medical problems to make cardiac issues a consideration, or immediate surgery a bad option, but I wonder how well we’re serving the patients by teaching the ER to avoid calling us with strange upper abdominal pains that they decide to admit.)

Dr. Drackman mentions his indecision, when he first noticed the patient’s rigid abdomen, about how pointedly to bring it to the MICU team’s attention. It’s a touchy point of professional etiquette, in less dramatic cases, about how much to interfere when you feel certain the other doctors are mismanaging something, but it’s not technically your patient.

When called into the MICU, I do my version of a complete surgical examination, trying to make sure that there’s no surgical cause for the patient to be septic. (Similar to how, when the orthopods are consulted on a trauma patient, they admirably make it their business to examine the patient’s joints from head to toe, and to lookat every film we got, whether we pointed it out to them or not, to see whether there are any fractures the dumb general surgeons missed.) After all, I usually conclude my notes, “no role for surgical intervention,” so I better be sure it’s right.

When the medical patients are in the surgical ICUs, it’s more difficult to stay away. You can see them through the curtains, spending three hours trying to get a few lines into a critical patient, and it’s a great temptation to go offer to help, but I don’t. That would be insulting, and I would probably fail miserably, for my pains. (Though to be fair, I heard the nurses the other day praising a critical care fellow for putting in the fastest lines ever, subclavian and a-line in twenty minutes. My best, so far, is about fifteen minutes for a subclavian, ten for a radial a-line, if the supplies are all handy.) Besides, in the surgical ICUs, the nurses will do a good job of gossiping at the desk: “Did you hear about that MICU patient in the other room? He’s been getting septic, and no one’s sure why, but I think maybe he has C diff. Don’t you think I should just go ahead and check? Ok, I will.” (Stool for Clostridium difficile toxin being, like a urinalysis or tylenol for a headache, one of the handful of things a non-ER nurse usually feels free to order on the assumption that the residents won’t object too much when she tells them.)

This morning I was rounding in the MICU, and walked past a room where the patient was clearly not doing well. I heard the nurses discussing “maxed on all pressors,” and the monitors looked like they were about to flatline at any moment. The resident was standing outside the door, looking miserably perplexed. I didn’t stop, for several reasons: the resident was somewhat of a friend, and senior to me, so it would be silly for me to give advice; if all the pressors were maxed out, that says there’s really not much left to do (except throw fluids at it, which is what surgeons always do, and what the medicine people hate about us); and the patient had that peculiar shade of yellow-grey which says that nothing you do is going to have much effect, any way. He died within an hour, as I later discovered. I’m still questioning myself, though. Maybe if I’d recommended a fluid bolus that would have kept him going long enough for something else to be done. Maybe I should have stopped just because my acquaintance looked miserable, although due to her seniority, I don’t think I know more than her just because she’s an internist. Maybe they’d already tried fluids; I didn’t check what the iv rate was. Maybe I was right not to say anything about a patient neither I nor my attendings had ever been consulted on, and whom I knew nothing about, beyond the plain fact that he was dying.

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