After writing that last post, I was set by the attending to go through the lady’s chart – three inches thick – and make a timeline of all the various warning signs in her past, and what had been done about them. At first I was afraid I would find that the residents, being still in training, and not “owning” the patient, would have failed her at some point. Thankfully, it turns out that she was warned and admonished at least five times over the past ten years about the need for a hysterectomy. And every time she would just disappear. To be sure, one hopes that in a private clinic, there would have been some more vigorous pursuit of her. But, legally and ethically the residents are clear in her case. It did take me an hour to document all that.

The big case of the afternoon was a nice lady who thought she was menopausal, and then turned up with an HCG of 300,000 – three times the maximum in a normal pregnancy. She was thought to have choriocarcinoma (basically placental tissue, no fetus, that becomes cancerous) – probably highly metastatic, since it had been brewing for nearly a year. I asked the attending (the nice younger one, who let me sew up some) if I could maybe make the incision. He reacted much as the chief did when I asked to help in a vaginal hysterectomy. Apparently I have very bad judgment in what I ask for, and have a great deal more to learn, if I think incisions are a simple place to start. (But where else, honestly? Opening and closing the skin . . . not too complicated, don’t you think?)

I knew it was not going to be a nice case when the scrub tech started being possessive with the suction. Middle-aged, shaved-head kind of guy. I uncharitably suspect him of thwarted ambitions towards surgery. I am of the firm opinion that the suction, and the suture scissors, and the lap sponges, belong to me. I may fumble a little, but those are unimportant enough that I can be allowed that gesture of involvement. All the other (female) scrub nurses have been very nice, handing me things and whispering to me what I can do to help. So, I object when the tech starts pushing with the suction, and making suggestions to the doctors about the bleeding. Now, you can’t help with the suction unless you can see where it’s going; and since we were both of the same height, I know he couldn’t see any more than I could. The third time he lifted the scissors away from me, to hand to the doctors or use himself, I just reached over and took it back. (Of course, it didn’t help that I next picked up what I thought were a pair of fancy metal clamps, to examine their function, and instead squished a tiny metal staple. It was not needed.) The doctors didn’t mind; they have always let me cut all the sutures, until the last few deep inside. (See how pathetic I am? I’m fighting about cutting sutures.) I thought perhaps they didn’t notice my silent war of glares with the tech. Until close to the end, when the attending glanced over at me and said, “Alice will just have to match into a surgical specialty; you can’t keep her away from the scissors – or the staples.” <turning crimson, very grateful for masks> But he was ribbing the resident too, for breaking the heavy closing suture with his enthusiastic knot-tying. He did let me close part of the incision again; I did it worse this time, making a “button-hole” – doesn’t look nice. But you have to be willing to make mistakes, and humiliate yourself, or you won’t learn anything – especially not in surgery.

Well, the frozen section came back that it was just a complete mole – which is placental tissue growing on its own, but it hardly ever leaves the uterus, unlike a partial mole, which is much more likely to metastasize as we had feared. So she will have a pleasant surprise when she wakes up.

In spite of having caught a bad virus, I stayed for evening rounds. As long as they think I’m a ridiculous gunner for surgery, I might as well be a gunner outside the OR too. And the chief had been telling the story of the time when he was an intern, on call, with a fever of 102, and he worked for 36 hours straight. I think subconsciously a lot of the older doctors (ie, older than interns) resent the younger people benefiting from the new rules. My silent answer is not to complain about anything that’s bad now; although the medical students on OB are pulling 36-hr call days, even when the interns aren’t. But that’s my secret.

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