surgexperiences


Chalk that one down for a learning experience.

The fact that we had admitted half a dozen patients the previous evening, and booked nearly all of them as add-ons in the OR should have been a clue that it was not going to be an easy day. Nevertheless, the plan was for all the other residents to be in the OR, and me to do work on the floor until one of the last cases, when I could do a minor amputation. Which was fine with me. Amputations are exactly the kind of case where they let the intern do the whole thing.

So I was just hanging out and watching, unstressed, letting everyone else worry about the busy ORs, when one of the seniors paged me: “Hey Alice, Dr. X had to go do this, and Dr. Y had to cover that, so I’m going to be with this other attending. . . so you need to go scrub in OR 12. All right?” I started explaining how thrilled I would be to work with the attending who had OR 12 booked solid for the day, and he hurried off.

It was supposed to be a simple case: access the artery, do an angiogram, maybe put a stent in, get out. I’m starting to learn that nothing in vascular is that simple. If these patients weren’t complicated, they wouldn’t be having vascular surgery. The procedure took twice as long as planned due to difficult anatomy. Finally, we were pulling all our wires and sheaths out. “Alice, just put your finger on the artery here while the nurse gets us a suture to close it with.” Famous last words. This is the third time Dr. Xavier (we’ll call him) has told me something like that, and every single time it ends with blood all over me and the patient. So I put several fingers and a good deal of pressure on it, and somehow there was blood coming out anyway. I’m not sure what happened next. I can’t believe that either Dr. Xavier let go of the proximal controlling loops, or that I was so stupid as to pick up my finger to see where the blood was coming from. However it happened, the next thing I knew there was a fountain of blood all over my face, my neck, my gown.

I pushed the rest of my hand over the artery, and it stopped. Dr. Xavier calmly looked across the table at me. “Carla, would you clean off Dr. Alice’s glasses please?” Silence throughout the OR. “Actually, perhaps it would be better if Alice went and washed off.” Grateful for the confirmation, I let the student get his hand on the artery (with a very determined look on his face), and scurried out to the scrub sink to wash my face.

I thought I had most of it fixed, but as I walked through PACU, pre-op holding, and the nurses’ lounge to get to a bathroom (they don’t provide much for female physicians at my hospital), I got some weird looks. Come to find out I’d missed large sections of the carnage, and looked like nothing so much as a zombie from a horror movie. Back to the sink. . .

A couple of CRNAs standing by assumed I had been banished from the OR in undeserved disgrace, and tried to comfort me. “Are you ok?” “Oh yes, I’m fine. I just should not take my finger off the artery ever again; stupid of me.” “Oh dear, honey, I’m sure that’s just what they said; it’s ok.” “No, I mean it seriously, I should not have taken my finger off the artery. On the other hand, I made a hole in it in the first place.” “It’s not that bad, I’m sure it wasn’t your fault. They’re just choosing to blame you.” “No, really, we made the hole on purpose.” “Oh. . . well, I’m sure it was a learning experience.” lol, talk about crossed wires.

Moral: never assume that any vascular case is going to be straightforward enough not to need a shield on the mask. But I hate the way those shields hit my glasses and pick up glare. . .

 (If you want to hear an even bloodier story, click here.

The other day I saw my first ED thoracotomy. For those of you who aren’t medically fluent, that means splitting someone’s chest open in the trauma bay of the ER in a usually doomed attempt to save their life by cross-clamping the aorta to prevent bleeding, and dealing with fatal holes in lungs and heart. The success rate if this is performed for penetrating trauma (gunshot, stab wound) is commonly reported as somewhere near 5%. Perhaps not that much, although we did recently have a guy be discharged less than a week later. The indications are few and far between: for blunt trauma (which means that the attempt will probably be worthless, since if the person is dying of a blunt chest trauma it implies a massive disruption of the aorta, or something else impossible to fix) it’s only strictly indicated the patient codes while being wheeled into the trauma bay, or shortly thereafter. For penetrating trauma, the rules are a little broader, involving loss of pulses anytime after the medics get there.

The trauma team was short-staffed. It was the kind of day where all the junior residents know they’re supposed to come and help if things get hairy and they can manage it. When the page went out, “trauma code, gunshot wound to chest, unknown male, intubating, eta 5 min,” we knew it was finally real. Our trauma center tends to do a lot of fake penetrating trauma: gsw to chest, really through the flesh of the shoulder; gsw to abdomen, a glancing blow across the flank; stab wound to chest, a 1cm flesh laceration; and so on; which are all billed as trauma codes, because they’re quote penetrating. But if this guy was getting intubated – that’s real. I was in the ER anyway seeing a flow of consults, and now I was just waiting for CTs to get done. I knew they wouldn’t happen while there was a trauma in the vicinity, so I had time to go see.

The trauma chief and intern always put on gowns, face shields, and shoe covers for these things, because you never know how much blood there will be. This time we all, including the attending, who rarely has to get his hands dirty, covered ourselves from head to toe in paper and plastic. The trauma bay looked more like an operating room than a space in the ER by the time the ambulance rolled up. The trama chief, who’s done this a couple times before and doesn’t really need instructions from the attending any more, was very organized, determined to avoid the kind of chaos that sometimes ensues when a trauma is halfway between nonsensical and deadly serious. He handed out orders: I’ve got the thoracotomy tray, you put in the left-sided chest tube, you do a cut-down and get access, you look for an ABG, you’ve got the airway, you help with the airway, keep xray out of here there’s no time for them.

One of the techs looked out the door as the ambulance rolled to a stop. “They’re doing chest compressions, guys,” he reported; and the chief broke the final seals on the sterile thoracotomy tray.

The medics wheeled in, transferring the patient onto our gurney, giving their meager report: gunshot wound, down for maybe twenty or thirty minutes by now, maybe more, pulses in the field, lost in transport, finally intubated a few minutes ago. Then there was a perfect storm of activity, but all in dead silence, because no one needed instructions, and we could all tell by the skin’s gradual transition from pink to grey that this story was not likely to have a good ending.

I think my mind did something funny, because I somehow didn’t even look until the chest was wide open and the chief had his hands deep inside, probing for the aorta to cross-clamp. Ok, so I had been assigned something else to do, but you would think I would look at the first time I’ve ever been present for this legendary maneuver.

It didn’t matter, in the end. The bullet had torn straight through the apex of the heart, shredding the muscle. A liter of blood and clots poured out when the chief had the chest open, and then the heart was loose and floppy in his hands. The hole was too big and ragged to do anything about, and there was no blood left inside to try to keep in, anyway. (Which makes me question the theory of his having had pulses until just before he arrived; I don’t see how he could have lived twenty minutes with that big a hole in his heart. Tamponade, maybe.) Somebody had good aim; unusually good aim; fatally good aim.

(The cops are kind of funny at these scenes. They hang around at the edge of the trauma bay, fascinating to us because maybe they know what happened, and we don’t, and most likely they’re going to arrest someone based on what our attending tells them. Then one of them steps forward as the assembled techs, nurses, and ER residents fade away, and asks, “Is he deceased, then?” And we all shrug, and I’m left to answer. “Yes sir, he’s dead.” His chest is gaping open and most of his blood is on the floor, there’s a tube in his throat that’s not connected to anything. Yes, he’s dead.)

Everyone else is gone now, and it’s just handful of surgery residents left standing in the blood and litter of papers on the floor. The man’s face is completely grey, a strange contrast to the blood scattered so liberally over the rest of his body, and indeed over us as well. Without a whole lot of conversation, the attending grimly motions us all over to the right side of the chest, determined to make sure that we all know what the aorta feels like when you’re hunting for it blind, arm reaching in past the elbow, the view obscured by the lungs being inflated by the ventilator, and no time to think. Based purely on feel, the chief had somehow separated the aorta from the heart above it, the esophagus beside it, and the spinal muscles behind it, and clamped it just above the diaphraghm. It felt strangely limp, unnaturally empty. For this guy it’s too late; but we’re not going to waste the opportunity, since nothing can hurt him any more, to learn things that could save someone else’s life in the future.

It was somehow not as dramatic as I’d expected, the actual event. Perhaps because the conclusion was so clear from the moment the medics walked in. Perhaps it would have been different if we’d really though there was a chance.

But it raised the same old questions for me: the chief tore this man’s chest open and plunged both arms in, recklessly dissecting down to the aorta. Will I ever be able to do this? Do I want to be the kind of person who can do this?

The chief said almost nothing, before, during, or after the incident. He’s grown a silent, protective face over the last year. I remember in July, his face used to give things away, and he would get hurt by it, when confronted by an attending in the OR or in M&M conference. Now his face is almost always the same, no matter what’s happening – years older and locked like a bank. He’s got two months to go on trauma; and that’s the only thing pulling him through; that, and his wife. So I think inside, things like this disturb him, too; but he doesn’t talk to us much about it anymore. Maybe his wife hears, but no one else.

They sent me on a donor run today. A donor run is when a transplant surgeon travels to an outlying hospital to harvest organs. As far as I can tell, there’s a call schedule shared between the transplant surgeons in a large area, but going out usually implies that you plan on using at least one of the organs at your own institution. Usually this is the liver, since this is the trickiest to harvest correctly, and the surgeon likes to know that no useful pieces were accidentally left behind, and no unrecognized variant arteries were damaged.

“They” sent me, as in the senior residents universally declined to go (bad time of day, weekend, weather, etc), and were secure in the knowledge that I would jump all over the opportunity if they let me. When I told the attending I was being sent, his response was: “You? !! Oh, really. I guess so.” Later on: “Why on earth did they send you? Where are the other guys? They’re a bunch of lazy slackers . . . I’m going to be grouchy about this for an hour. Go to sleep.” Five minutes later: “Do you tie well?” Me (afraid to claim something I won’t be able to live up to): “I wouldn’t want to say that.” Surgeon: “You should be able to tie well. If not, you should be practicing. If you can’t tie well, no attending will let you do anything. . . So, Alice, can you tie?” Me: “Oh yes, very well!”

This surgeon is young, dedicated, ambitious – aggressive, even. He makes himself available at all hours, ready to go on donor runs at any time, and then come back and spend the next eight to twelve hours transplanting what he harvested. I called him once at night to say I felt uncertain about a patient. He reassured me over the phone, and then fifteen minutes later turned up in the patient’s room, sitting down to chat with him, and then to explain the lab results to me in detail.

He holds himself to very high standards, and he demands the same from the residents. When he called to tell me to go on this run, one of the senior residents remarked, “He’s an old school surgeon. If things aren’t exactly right, he’ll get upset. Don’t take it personally.” I’m still not sure what he was talking about. I take this attending’s remarks personally to the extent that I’m pleased he recognizes me now, even if he’s not exactly thrilled to have me with him. I’ve made mistakes around him, and he knows that. On the other hand, after a few hours of sleep, he was much more cheerful, and by the end of the trip kept repeating how much I’d learned today, and how I would learn even more, and get to do more of the procedure, on future runs. I know that I don’t know enough – anatomy, surgical technique, transplant lore – and the best way for me to learn more is to have him firmly unhappy when I don’t work hard enough.

As for the procedure itself, what can I say? Regard for current news prevents me from going into much detail, except to say that the patient had sustained clearly unsurvivable injuries, and was pronounced brain dead before we were even called. The entire proceeding was marked by respect for the family’s wishes (allowed to take this, not allowed to take that, make things look good for the family), and some (limited) sorrow over a young person’s tragic death. Not too much of that, however, because frankly this is a brutal procedure, and the only way to do it is to completely block consideration of the donor as once-living (he’s dead now, completely dead now) and to concentrate on the patients whose lives will be saved by what we did. I did my best to do exactly what the attending wanted, and although my skills still leave a great deal to be desired, I did tie well enough not to tear blood vessels or leave them leaking, and at least I answered all the anatomy questions correctly.

Some people question the ethics of transplantation, denying the existence of “brain death.” I’ve thought about this a fair amount, since this would be absolutely impossible to do if there were any question of the donor being in any sense alive. (Remember that one of my reasons for staying out of ob/gyn, in the end, was concern about the abortifacient nature of contraceptives, since almost every single one acts in some aspect by preventing implantation of a conceived child.) I concluded in the end that brain death, when rigidly defined (absence of every single brainstem reflex, no confounding circumstances, after extensive testing) and properly diagnosed (by two doctors from separate services, apart from the transplant surgeons) is a real entity. This patient, for example, still had oxygenated blood flowing to his organs, but only because of aggressive ventilatory support and several iv pressors. In fact, our work was made more difficult by the fact that he was becoming very difficult to oxygenate, or to maintain a pressure on. He was indeed dead, and his body was on the edge of shutting down despite all our technology. We hastened nothing. I think some of the lay objections stem from a confusion between brain death (the concept that the brain is as vital an organ as the heart or lungs, and once it stops working, the rest of the body will follow shortly) and “permanent vegetative state” (which is a vague and difficult to diagnose condition in which the person breathes on their own, but doesn’t seem to respond to stimuli; this is what people recover from on very rare occasions). People cannot recover from brain death.

I’m going to have to stop talking about best days ever, because this is all good. The last few nights I and the other night people have been seeing one case after another of those “classic” things, where it looks like the textbook, sounds like the textbook, and even was caused by all the risk factors in the textbook. Not really famous cases, but I’m always tickled to find out that things exist in real life, not just in textbooks and legends. (Gallstone ileus, cecal volvulus, intussusception – that kind of thing.)

Several nights back we had a med student on call, and there was a unique case going on. It was the first I’d ever seen or heard of, and the resident doing it also knew it only by anatomical drawings. The attending was a great teacher – ok, so he whispers and has a thick accent, but if you listen closely, you learn a lot. I called the med student, told him what was going on, and encouraged him to go see the case. I think he went to eat dinner first, which is not laudable, but not reprehensible either. Maybe an hour later, I finally had enough free time to go back to the room. They weren’t very far into the case, but the med student wasn’t scrubbed in. He was just standing in the back, flipping through the chart, while the surgeons sliced smoothly through to expose some beautiful anatomy. I observed to the student that he was allowed to scrub in. I admit that I wasn’t too forceful about it, because I knew that in about two minutes I would be invited to scrub in. I did, and the medical student drifted off, to go study for the SHELF, maybe. It was a tremendous case: easy to see anatomy, the surgeon a great technician, teaching the whole time both about the pathology, and about how to use instruments. FYI, students, that’s one way not to make a hit on your surgery rotation. Always always always scrub in whenever possible. It’s what we live for, and we can’t really fathom why anyone would not be interested. (And yes, this student wants to do psychiatry or something like that, so he has an excuse of sorts; but not really.)

So this morning we had another one of these gigantic cases, the same kind of thing which not too long ago I found myself assisting at, and tremendously annoying the surgeon by doing so. Thus, when I knew a similar case was on this morning, I resolved to come only to watch, with no hopes whatsoever of scrubbing.

I guess my efforts to rehabilitate myself in that attending’s eyes (by studying the subject, and showing up at all times of day whenever he’s doing anything, and doing my best to assist exactly the way he says to) have paid off, because he was quite friendly, and invited me to scrub in right at the beginning. (It’s a good thing that my reading the day before actually covered that case, so I had some vague idea, finally, of what I was looking at.) I had a great time. It was a complex case, with plenty to do, and I got to do half the work on a fair piece of it.

The only drawback is that it took me all week to catch my sleep cycle up, after staying up all day for that first case; and now I have to start all over again.

I am, I regret to say, quite pleased with myself, which will no doubt get me in big trouble tonight. But for last night, it was great.

They finished with a complex and unusual surgery and took the patient back to the ICU. Somehow he was now my responsibility. The attending and resident left to go home to sleep for a few hours, after leaving me with complex and detailed instructions covering most possibilities.

Of course, as soon as they were quite out of the building, something else happened. He needed a chest tube, or rather, a pigtail catheter. This matters, because I was fairly sure I could do a chest tube, but I had never before seen a pigtail put in (it’s a much smaller tube for draining only air out of the chest cavity, when you don’t expect to find blood, and thus don’t need a large chest tube). The nurses seemed equally uncertain about where to find the supplies, or what to do with the supplies once we had them. Meanwhile the patient’s vital signs became more and more unstable, reminding me very unpleasantly of those questions which occur on every single test from third year medical school up till specialty boards, about the patient with hypotension and tachycardia and absent breath sounds on one side, who will die unless you perform an immediate needle thoracostomy. If you wait and do a chest tube, you always get the question wrong. Now we see why tests are bad for you, because this patient was still ok, but I have seen so many of these questions on tests that I got needlessly concerned about the possibility.

Fortunately at this juncture a senior resident wandered by, noticed the large congregation in the room, and stopped to see what the fun was. He pointed out a couple of errors I was about to make, and with his supervision the catheter got in the right place. (Rather to his surprise, since he seemed not to have done many of these either.) Everyone relaxed. The senior resident left to attend to his own patients. The congregation dispersed.

And then it turned out that the patient had inadequate iv access. Very inadequate. Moreover, nearly every site you could imagine trying was unuseable, for various reasons, including the fact that several attendings had already tried to place central lines, and failed. The nurse, however, continued persistently to fiddle with the lines, and every time I suggested giving him some treatment (because his blood pressure continued to be erratic), she would remark, “That’s fine, but how do you want me to get it into him?” and continue with a litany about how every line was either blown or already in use. So (again with a little supervision) I put in a line, in one of the spots that the attendings had already failed on. That’s why I’m now inordinately pleased with myself; and it’s nice that the senior residents kept walking by and being impressed, too.

I feel like a surgeon. I can do (difficult) lines and procedures on an unstable patient, and be successful, and the patient survived (so far, at least). I made some other decisions, too, which caused the seniors (who were suddenly much more interested in hearing about my problems than they were the last couple nights) to raise their eyebrows and make remarks about clinical indications or the absence thereof – but the morning labs bore me out.

I know that tonight I will get in trouble, because it’s impossible to be so happy with myself, and not make a mistake. “Pride goeth before a fall.” So I remind myself that I was being supervised (some of the time), and that really it was more my good luck that things turned out ok, rather than that I knew precisely what I was doing. Moreover, next year I’ll need to handle, not one, but several critical patients at the same time. This one alone occupied my whole night. I still have a long way to go to being able to balance several ICU’s worth of patients – in four months.

Part of the fun of the night was working with the ICU nurses. They make a great team for each other, always moving to share work whenever anyone’s patient becomes too critical. For this particular patient, since it was such an unusual case, and neither they nor I knew much about what to do, we got along very well: they told me whatever they could remember of “what we did the last time this happened,” and I told them the specifics that I had gathered from the attending’s hasty and detailed instructions, and we did fine.

I am very excited to announce that in two weeks I will be hosting the tenth edition of SurgeXperiences, a blog carnival dedicated to all things surgical. So please submit a post (or two) regarding your experience with surgery right here. The deadline is Dec. 7 (or 7 Dec, as most of the world says it). There is no particular theme to this edition, since I am a fan of the now old-fashioned (if you can call a thing old-fashioned when the entire forum of blog carnival has only existed for a few years) idea that a carnival should consist of the best of the contributing blogs – on whatever subject their authors choose to write about (as long as it’s somehow related to surgery).

While you’re thinking of what to send in, check out the current edition here at Monash Medical Student.

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