transplant


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.

Sorry for the light posting, folks. Life is extremely dull these days.

Which leaves more time to observe the political delicacies of the transplant service. Transplant is unique as a surgical specialty, in that it is a surgical cure for a medical disease. Normally, there’s no surgical role in diabetes, renal failure, or cirrhosis. But once the patient is sick enough to have a transplant, the surgeons and internists have to work together. Very closely.

I don’t know how other places manage it, but nobody has ever defined, here, exactly who is in charge, although everybody agrees that I get to admit and discharge all the patients. There is a great deal of collegial conversation among the attendings (“I trust Dr. Smith, let’s do whatever he says;” “don’t worry about it, I’m sure nephrology/GI/endocrine has it under control”). The residents and fellows also do a fair amount of the same, perhaps a little more barbed (“Good morning, I was just wondering what you thought about. . .” [which being interpreted means, what on earth where you thinking when you did this?])

And then I end up in the pleasant situation of the patient asking me the meaning of a test I didn’t order and had no idea about, or the purpose of a medication I thought he wasn’t supposed to be on. Or better yet, the attending asks me what the immunosuppression is/what the iv fluids are/what the blood pressure medications are, and whatever I tell him is wrong, because someone changed it since I last looked at the chart.

The key seems to be politeness, no matter what you think or are saying, because as long as you say, “what on earth was the point of that?” or “did you not notice this major problem?” in a very polite way, you can keep working together. And I’m sure the nephrology and GI fellows feel the same way about me; perhaps with more justification, because after all, what is a surgery resident doing with these medical patients?

You may perceive that my ambition to know all about medicine has long since vanished. I don’t care about the intricacies of lopressor vs atenolol, or all the possible ways to control blood sugar, or unasyn vs zosyn. It doesn’t need to be cut, I’m not particularly interested.

Bonus: after he counted me coming in at 5:30am for nine days in a row, one of my patients told the attending, when we rounded several hours later, that I was an exemplary doctor and deserved a raise and/or a day off. Makes things worthwhile.

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.

Some friends at church asked me what my favorite kind of surgery was. This blog has given me the bad habit of being frank about my job, so I said, “Vascular surgery, because if you miss a stitch, blood shoots up at the ceiling.” They were rather horrified, and began relating how they had been traumatized by dissecting fetal pigs in high school or college. 

Note to self: There is a reason that most doctors never talk about their profession outside the hospital or clinic. From here on, even if people ask pointed questions and seem to be genuinely interested, I will say nothing. I will be a monument of discretion (yeah, right).

Which brings me to my least favorite part, at least of transplant surgery: dissecting out the external iliac artery and vein using electrocautery. This works out to the attending surgeon isolating pieces of tissue which he thinks do not contain any tiny blood vessel branches, and then me bovieing through them. So I’m holding one end of a 9″ long bovie, manipulating the other end deep in a hole, 1mm away from two very large blood vessels. This strikes me as an extremely bad idea. I still don’t know 1) how I get up the nerve to do it every time 2) how come I’ve never hit the wrong thing yet. But I guess that’s the whole point of surgery: cutting small things, surrounded by larger objects which it would be dangerous to cut; if you don’t get comfortable with that, the operation takes twice as long as necessary, to the danger of the patient and the annoyance of everyone else in the room.

The other option is perhaps safer, but not easier for me: right-angle clamp around a tiny vascular branch, pass two silk ties around it, tie off on both sides, and then cut in the middle. Which works out to 1) only 1 out of 5 scrub techs ever seems to grasp the concept of handing ties in a way that is of any use to the surgeon who only has one hand free for it; the attending doesn’t see the antics they’re getting up to, and not-quite-silently blames me for not completing the maneuver faster  2) the attending gets to critique my handling of the ties, and then my method of tying, over and over and over again. Which means I learn a lot, sure. . .

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.

Finally, some action. Went on a donor run with an attending I haven’t worked much with before.

My main conclusion from this is, that the popular conception of surgeon’s hands as delicate is quite wrong.

The attending handed me about eight liters of ice to break up (to pack into the abdominal cavity to cool the organs after cross-clamping), and instead of, like other transplant surgeons I’ve worked with, growling in frustration after watching me for five seconds and taking over, left me to finish the job by myself. Which was salutary, but painful. Between the ice and the hammer, and then tying knots in nylon afterwards, my hands are all scraped up, and my arm is going to be sore for days. I need to take up weightlifting.

The surgeon not knowing me was also nice because he assumed that anyone sent would be familiar with the proceedings, and let me actually cut a lot of things. Since he kept talking as though I was a senior resident (I did explain, eventually), presumably I didn’t do too bad of a job. Real surgery, finally. Now I just need to work on the sewing-up-after-cutting part.

I’m bored. I’ve resorted to two strategies which are the resident’s equivalent of standing on a bare hill in a thunderstorm and holding a piece of metal: strolling through the halls discussing how bored I am and how much I would like anything at all to happen, and sitting in the nurses’ station rather conspicuously napping, reading a sci-fi novel, and following political commentary on National Review, which is pretty much begging for the nurses to decide I don’t have enough work to do, and to come up with some for me. They didn’t. All that happened was I got tired even of the novel (not as good as the book it’s a prequel to), got tired of reading about Obama and Palin, and was forced to read a chapter of Greenfield online in order to stay awake.

My white cloud has come back with a vengeance; for a while there on trauma I thought I’d shaken it for good, but no. No transplants in sight. All my patients are getting better, and very few new ones are coming in. (Somebody remind me how much I hated it when my patients were dying; I ought to at least enjoy discharging people to home for a change.)

This whole home call concept takes some getting used to.  One of the major lessons I learned last year was how to be on the spot: if a patient’s sick, you don’t wait to get called, you keep walking by. If you do get called, you give some preliminary orders (oxygen, fluid, ekg) on the phone, and then get over there so you can see for yourself. And you don’t leave in five minutes; if there’s nothing else urgent, you stay around to see how things go; work on the computer, make some calls, but stay handy for a little bit. And of course the cardinal lesson in medicine: trust no one, neither those junior to you nor those senior. Everyone lies; verify it for yourself.

Now I have to reverse that. I’m getting a little better at jumping wide awake in the middle of the night, so the intern calling doesn’t have to repeat himself ten times. But you have to have all the answers – maneuvers, tests, medications and doses – completely memorized; that’s the only way they’ll come out coherently at (ahem) 3am. (How about my attending for president? He’s really good with the 3am phone calls. And I’m sure he’d come up with a more practical healthcare policy than the politicians have.)

The worst part is not being there. I have to trust the intern (fortunately the ones I’m working with are quite competent) to assess the situation correctly; without seeing things for myself, I have to figure out the key information, and think of things to ask about that the intern may not have considered. Then we come up with a plan, he hangs up to go do it – and I’m supposed to go back to sleep, instead of lying there worrying about whether either of us missed something, whether the patient is going to get worse before our treatments take effect, whether I misjudged the significance of a piece of information, whether I told him the wrong dosage on a medication. If I were in the hospital, I’d keep looking over the labs, ekg, chest xray, till I felt more confident. But I can’t keep calling the intern to go over things again.

(A bonus last week: in desperation, I dredged up a treatment I’d read about as of historical value only, but it was the only thing available or applicable for this patient. Not fun to play that card from long distance, but next morning the patient was nearly all better. I don’t know whether that old-fashioned trick did it, or whether he wasn’t as sick as we thought. Remind me not to read the historical section of the textbooks, it leads to unsettling decisions.)

Going back to sleep is also tricky. After getting called, I spend the next couple hours unable to sort out whether the phone ringing and the patient deteriorating are happening in my dreams or in real life, and I can’t shake the feeling that it’s really high time to get up and go to work, no matter what the clock says. I used to react the same way to pages at night on call, so hopefully this will get better with time.

I’m having a great time with transplant. Still haven’t really had much in the way of surgery to do, but with the whole weekend ahead, I’m hopeful that something will turn up.

Otherwise, this is great. Some surgery residents dislike transplant, because you have to do so much medical management (by definition, a transplant patient has lots of serious medical problems – diabetes, difficult-to-control hypertension, history/risk of strokes, cardiac problems, liver dysfunction), and because they regard this rotation as a waste of time, since so few residents actually consider transplant as a career. I don’t know what they’re complaining about. I don’t want to do transplant (it has to be the worst lifestyle outside of neurosurgery: completely unpredictable, with the potential to get swept into spending several days on end in the hospital at any time), but the rotation is good.

After the craziness of trauma, I feel like I have a normal life now, for perhaps the first (and likely only) time in residency. I can get out of the hospital in time to hit rush hour traffic. I’m not spending the entire weekend in the hospital. The laundry is getting done, the house is getting cleaned, I have time and energy to cook real food (I must have discovered the toughest cut of beef out there; got it because it was cheap; but it was still better than hospital food), and I have time to read both textbooks, science fiction, and a commentary on Samuel that’s been collecting dust for six months. Life is good.

I started reading Greenfield’s section on transplant. It starts with a 30 page chapter on transplant immunology.

It’s taking me about five minutes to read each page.

This is going to take a long time.

(There are the occasional hilarious comments, such as “Presumably, these multiple V region families arose by an evolutionary process of gene duplication followed by mutation of individual family members. . . the combinatorial possibilities are extremely large, showing why the immune system is able to generate antibodies for virtually all known antigenic determinants.” So they write this long chapter to explain how little they understand these cellular processes, but how miraculously well they turn out – the human immune system works against virtually every virus and bacteria – and conclude that it’s all a matter of random chance. No possibility that an intelligent Designer arranged everything that way on purpose.)

I’m still only two pages in.

Hopefully this will go faster when I get to the clinically relevant sections. . . fifty pages away.

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