surgery


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.

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.

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