transplant


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.

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.)

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