Thursday the elderly vascular surgeon told me there would be a femoral-popliteal bypass, and a carotid endarterectomy the next day. I made a guess, and read about the endarterectomy. That one didn’t happen till we were in class in the afternoon.

The bypass patient was a nice middle-aged man, not that old, who was discovered to have large bilateral popliteal aneurysms after he presented with a cold and painful right foot. It had improved slightly with tPA (which apparently is very good for breaking up peripheral vascular clots, and has no time limitation, but absolutely cannot be used after surgery; so you usually give it a shot, if you think there’s a little time to work with, before moving to surgery), but the angiogram showed large aneurysms, and embolic blockage of the smaller vessels in the right foot. So, it was proposed to bypass both aneurysms at the same time, using the superficial femoral vein as an autograft.

This was one surgery with enough room for everyone: the attending, the chief, a senior resident, the ortho intern, and me. The chief took one side, watched by me and the intern, and the attending guided the senior resident on the other side. They started off by carefully harvesting the veins: dissecting them out, tying off all their branches, and then removing them to soak in heparin solution while they exposed the popliteal artery. The approach involved cutting through the semitendinosis tendon, to the horror of the ortho intern, although the attending insisted it would be unnoticeable to the patient. When they were down to the artery, they slowed down to one side at a time, so the attending could supervise the residents carefully. The chief of course had some experience, and moved fairly quickly. He did the right side, passing the venous graft through a tunnel along the popliteal artery, making sure it didn’t get twisted in the passage (otherwise the high-pressure arterial flow would torque it shut), sewing it onto the popliteal artery first below the knee, right above where the blood vessels to the calf branch off, then at the top. When the graft was in place, he ligated the popliteal artery so it wouldn’t be able to throw clots downstream anymore. Now the right foot picked up a posterior tibial pulse; the dorsalis pedis had never been found by us, and was assumed to be irreversibly embolized. At that point I had to leave for class.

During the afternoon I found one of the nicest OB/GYN attendings in her office; she takes students on trips to Africa. She kindly invited me in. As soon as I mentioned “third-world country” and surgery, she said, “I wish you would be an ob/gyn; but if that’s where you want to go, you should really do surgery.” She went on to describe some surgeons she had worked with at hospitals in rural areas of Africa, and said that she admired their ability to treat a wide variety of needs, and save lives with skills that she did not have. She agreed that it would be possible to learn basic ob/gyn surgical skills quickly after doing a surgery residency. So, I guess, if I’m looking for a sign from God, everyone I ask agreeing in the same direction really has to count. I’m having a hard time switching off the track I had set my mind in for so long, of doing ob/gyn. But, I also hate to leave any challenge untaken. And being a woman in a specialty where even now only 25% of the residents are women has to count as the closest I can come to imitating the pioneering women doctors whom I admire.

I’ve been a little concerned because of the kind of language and humor that is so prevalent around surgeons. But I’ve been reading a biography of C.T. Studd, a famous cricketer who became a missionary to China, India, and Africa; and some of the revivals that he led in England occurred among medical students, who would have been probably some of the most skeptical people in England at that time. So maybe I should be thinking in terms of changing this part of the world, rather than it changing me.

Anyhow: Friday evening I went with the intern on call to see this same patient in the recovery room. The nurse was concerned because she was now unable to discover his posterior tibial pulse, even using a Doppler. The intern checked, and couldn’t find it either. So he called the resident, who eventually came, couldn’t find it either, but did take down the wound dressings and find a doppler-able popliteal pulse; so the graft was still patent then. The resident did call the chief, and the attending, and let them know. The patient was then started on a high-dose heparin drip.

Then the intern and I went to see a consult in the ER. Only because the intern was new to the hospital, I was able to help him some, and felt a little more hopeful about myself. On the other hand, we then went with the resident to see some patients whom the nurses were concerned about on the floor, and both the intern and I were clueless. For example: the A-line reads a good BP, but needs to be taken out, and the cuff is reading a low BP. Final conclusion: put the cuff on the arm the A-line was in, where it gives better readings. It occurs to me now, that patient, who had had the carotid surgery, probably is getting ready for subclavian steal syndrome on the other side; I need to check on her on Monday. Or, patient nearly fainted, with BP down to 60, and just barely recovering. Here we were rescued by an ER nurse who was helping out upstairs, and had already gotten an EKG, drawn labs, given a fluid bolus, and hooked the patient up to a cardiac monitor, and arranged for atropine to be handy, by the time we arrived. I wouldn’t have had any idea to do all that; the fluid bolus, maybe the EKG; but the atropine, and the labs? I need to get the interns to take me to those annoying floor calls more often, so I can have some idea what to do when I get there.

In the morning, I went to check on the guy with aneurysms. He said no one had looked for pulses in the eight hours overnight that he’d been on the floor. I couldn’t get the posterior tibial with doppler, of course, but I was bold enough to take off the dressing again (which the intern hadn’t dared the night before; but it was falling off anyway), and couldn’t hear a popliteal pulse either. For once, the diagnosis and course of action was clear to me: something blocking the graft, need to call a resident quickly. Fortunately, at that moment the attending’s partner walked in, agreed that the graft was blocked, and arranged to take the patient to surgery for a revision that morning. I’m very much afraid that by the time I get back tomorrow morning, he will have had an amputation. Which is too bad, for an otherwise healthy man, who had no warning of all this just a week ago.

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