Monday the doctor had two spinal fusion cases to do. He himself suggested (we were afraid to) that both of us didn’t need to be at each. We both had the idea that whoever stayed for the morning could go home early, so I let the other student have that one. After lunch, as we were walking back to the OR for the second one, the resident who had been there in the morning walked by and excused himself to go to another case. He offered to send a PA to help, but the attending said he had me to help. Ha; I felt on top of the world. As we shall see, pride goeth before a fall.

For three hours, it went beautifully. Of course I didn’t do much as he opened her back, and pushed the paraspinous muscles away; I just held the suction, and tried to anticipate what he was going to do next. I figured he would go on and put all the screws in himself, which would obviously be faster. No; for the whole half on my side of the table, he would put in the probe, and after an xray confirmed its correct location, he let me take it out, put in the guide wire, screw in the scout, take that out, and put in the big heavy screw. Amazing. I got pretty fast by the end, although it became obvious why all the orthopods are men. It takes some strength to screw metal into bone, especially young healthy bone (not like the osteoporotic fracture I saw last week). He put the rods in, and let me help with screwing the top cap thingies on. He said later he’s never let a student do seven screws like that.

Well, the final steps included drawing some bone marrow out of the iliac crest to mix for a bone graft for the fusion, placing an epidural catheter and guiding it under direct vision into the spinal canal, and sewing closed. Once the epidural was in, he taped it lightly to the drape, and both he and the anesthetist warned me not to pull it out at the end of the case. (everyone hear the ominous foreshadowing music?) Then, he let me help suture the fascia and subcutaneous fat closed – which before he had insisted that only the resident could do. If I do say so myself, I managed to get it tight enough at the top that it didn’t bleed through.

Of course, you can all see where this is going. Once he had got the skin sutured, and tied the last knot, and handed the last instrument back, I pulled on the drapes helpfully to start cleaning up – and out came 6cm of the epidural catheter. Felt horrible for messing up his careful work, and looked for a hole to sink into, in anticipation of a thorough tongue-lashing. Actually he didn’t say much, just cut through all the sutures there in the middle, threaded the catheter further back inside the spinal canal, and sutured again, tying knots onto the loose ends.

Morals: Not to answer arrogantly when warned not to do something stupid, because that will inevitably lead to doing that very thing. Also, to consider whether I can ever make a worthwhile surgeon, if I am so incredibly absent-minded. At the moment, I wasn’t trying to do anything, except help in one way which had always been good before. Someday, I am going to overlook something really vital, and someone is going to get hurt – and maybe I shouldn’t get myself into a position to do that. Someday I’m going to cut something really important; maybe I shouldn’t try to get scalpels in my hand. . .

The other medical student had walked in just in time to see this. She’s a sweet girl, but horribly annoying to work with – of course, after that horrible blunder, I feel that I have no right to analyze her shortcomings at all. I don’t know which is worse: me guessing, and hitting things right, and being mostly responsible, but sometimes wildly and disastrously wrong, or her being careful and methodical, and so slow it hurts to watch or listen to, so far behind that she’s always asking truly dumb questions because the answer was mentioned in the last sentence or two. The closer I work with her, the more I’m starting to be concerned about her becoming a doctor; but surely the preceptors will say something if she’s really impossible; and who am I to say anything? Personally, I’m afraid of me being a doctor, at least as much as of anyone else.

Well, as we went up to change, she told me that she’d seen one of the interns last week create a pneumothorax while trying to start a central line, and she was disturbed by the nonchalant manner in which the older residents encouraged him, as though it was nothing big, saying it happened every so often. Myself, I will be truly astonished if I get through a surgical internship and learning to place lines without making at least two or three pneumos, and whatever the other major complications of the big bedside procedures are. That goes with the territory. It’s too bad for the patient, and I know I’ll feel awful when I do it, but while you’re learning a technical skill, you’re bound to mess up sometimes. What worries me is my absentmindedness. It shouldn’t take a great deal of either experience or intelligence to avoid pulling on a delicate, unsecuredĀ line after being warned.

Maybe I should mention that when the CRNA turned that patient over after the surgery was done, he discovered that his central line had infiltrated, and she had about 500cc of iv fluids collected in her neck. I don’t know where that fits in.

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