First case this morning was a lap choley on a patient with an old gastric bypass. The chiefs generously allowed the second year to scrub on it, but even so she didn’t get much to do, because the colon and gallbladder were all adhesed together, and the attending did the dissection himself, and just let her scrape it off the liver when he’d cut all the important things. The real drama to the case was the fact that this older attending had forgotten that he had a case scheduled, and had to be called at home and reminded, thus messing up the whole schedule, and setting us up for a sticky start with the chairman, whose case was to follow.

I introduced myself to the next patient, a young woman with a mysterious posterior mediastinal mass, which was unable to be biopsied by any approach less invasive than surgery. The chairman’s plan was to put in a scope to see if he could resect the mass through it, and then decide whether or not to do an open thoracotomy. Her mother was in the pre-op room with her, and was telling the CRNA as I approached, “Now, there aren’t going to be any students, right? I really don’t want any students to touch her.” Being more bold/callous/insensitive than I was last year, I didn’t decide to go to the library at this point, but introduced myself and said that I would be observing, if that was ok with them. The daughter obviously cared less either way than her mother, who said that she had had a colleague at work who had a “dropped lung” because of a medical student’s attempts. I repeated that the surgery was complex, and I would only be observing. And then proceeded to feel very guilty for the next hour, because of course I intended to do more than observe. I hadn’t said it in as many words, but I gave the impression that I would be standing on one side with my hands behind my back – rather than scrubbed and holding several objects, as I ended up. I hushed my conscience with the two facts that the patient herself had not been particular, and that I was definitely not hurting her – especially since the procedure required a dropped lung in the first place. (I’m wondering what the mother is making of the chest tube as she meets her daughter again this evening.)

As the chairman, residents, and I walked back to the OR, he noticed my million-dollar bills. I cowardishly handed him one, with the admonition to read the back sometime (rather than actually explaining what it says about the Ten Commandments and sin). To the amusement of the two residents, who had already gotten one from me, he stood in the middle of the hallway and proceeded to read the lecture out loud, while I fidgeted nervously: “Have you ever told a lie? Well, I guess a couple. Have you ever stolen something? I don’t think so.” Resident, mischievously: “Are you sure, Dr. Chairman?” “Well, I suppose once. Have you ever looked at a woman lustfully? Did you know that Jimmy Carter answered that question to Playboy truthfully, and it hurt him politically? You are a lying, thieving, blasphemous adulterer – here Alice, you can have this back, it’s too gloomy!” Since my worst nightmares had come true (I am ashamed to admit that I had avoided carrying the bills for the first week of September, out of fear of him), and the chairman had gotten himself involved in my evangelical activities, I figured I might as well go whole hog, and explained, as we put on hats and masks, that the point of the paper was to draw attention to the necessity of believing in Jesus for forgiveness of sins. He dropped the subject. But he had first preached the gospel loudly in a busy hallway. God’s got the joke on me; that should teach me to stop being afraid of this guy, or anyone else.

About an hour into the operation, I decided that I was less of a threat to the girl than the chairman was. Upon first putting in the scope, he identified as “the mass” an object which to the three residents and me looked suspiciously like a normal bit of lung. We raised our eyebrows at each other, and mutually decided to keep quiet as long as possible, to see if he would figure it out for himself without us undertaking the intensely dangerous job of explaining to him. After some five minutes of poking around, he realized that the mass was not visible, and converted to an open thoracotomy. Here I remembered why I first fell in love with general surgery, and even once admired the chairman: one of the first operations I ever saw was him doing another thoracotomy. The idea of a specialty which allows you to move smoothly between abdomen and chest and extremities, unlimited to one organ system, was and is fascinating. And he seemed especially wonderful then: splitting the chest open, dropping the lung and grasping it with retractors as though manipulating the organ of respiration was an ordinary occurrence, and revealing the beating heart behind.

Today was, for me, the best all month. I got to stand on one side, holding the lung out of the way and suctioning, while the chairman and one of the chiefs dissected painstakingly away at the mass, which was revealed to be very firm, and densely adhered to surrounding structures. I had a tremendous view of the anatomy, and could watch the diaphraghm and heart moving endlessly. The chairman himself was a less satisfactory prospect. At every step he exclaimed anxiously, “Ooh, I’m not sure if it’s safe to cut this. . . .” snip . . . . “This could be the esophagus, I don’t think we should go much farther here. . . . .” snip So that at every bit of dissection he proclaimed his uncertainty. I’m not sure if other surgeons feel this indefinite, but they surely don’t voice it. He had the resident and the anesthesiologist and the scrub tech and me all on tenterhooks for three hours. As he kept repeating his uncertainty about the location of the esophagus, I said, “perhaps it would help to put an NG tube down.” He acted totally enlightened by this suggestion, as though this simple idea had not and would not have occurred to him. (This was where I decided the mother should be grateful to me and the resident for helping the chairman, rather than resenting our presence.) But, I definitely redeemed myself in his eyes for the incorrect answers on rounds the past few days.

Eventually, he decided that it would be impossible to get the mass out without taking some of the lung and esophagus with it. And without knowing whether it was a lymphoma, or simple infectious histoplasmosis scarring, or what, that would not be worthwhile. He snipped out a piece for frozen section, and a piece for culture, and sent me to take the one to pathology. There, the pathologist exclaimed in horror at the small size of the sample, saying it would be totally inadequate to test properly for lymphoma, and demanded to know the surgeon’s reasoning. I did my best, but since I didn’t understand it anyhow, and thought that he could easily have excised two or three times as much with safety, I didn’t placate the pathologist much. He declared that he was unable to rule out Hodgkins, and would have to do further studies. I returned to the OR, where the chairman demanded to know what on earth the pathologist’s reasoning was, and was upset with my inarticulate explanation. Remind me not to run errands between two independent attendings again. So now the poor girl has had a huge thoracotomy, leaving her with an NG (because of the chairman’s paranoid fear that he might have injured the esophagus; I say that a little confidently because the residents voiced a similar disappointment with his management) and a chest tube and several days of hospitalization, maybe for nothing. Her original complaint was pain. I enjoy these surgeries tremendously, but I haven’t seen them do the patients much good yet, and nothing would ever persuade me to consent for a thoracotomy – especially not by the chairman!

For the rest, one of the chiefs spent the day grouchy because he feels abused by the other senior residents (handing him extra call days to cover for them, then refusing to help him out with all the pagers he’s covering so that he can have even one day free). He took it out on the junior resident, who likes him, and sympathizes too much to resent his verbal abuse, and calms herself by excusing him to me privately. (And yes, if you are thinking that residencies in general, and surgery in particular, have unhealthy abusive relationships between hierarchical levels, you would be correct. It’s slavery, only alleviated by the fact that you decided to be part of it, and eventually you get to give orders and abuse instead of take it.) The other chief is garnering their joint resentment by dodging the team’s work, and sleeping in the library. I try to keep my mouth shut, and not let on which ones I like better. The junior resident is doing a fairly decent job of this, giving reports to both chiefs equally, and taking orders meekly from both of them. Talk about serving two masters. I am accumulating a list of things to do and not to do when I’m a resident: Always go to see patients at night when you get called as an intern, so that the attending and chiefs of the other service don’t jump on you in the morning to question your management. Don’t switch your call schedule unless it’s really important, and be sure to pay back the favors that you to those who helped you. Never sit down quietly unless you’ve checked with everyone else on the team that all the work is done.

After we finished the chest case, the chairman took the resident and me to the attendings’ private lounge to eat a very belated lunch, and spent half an hour telling anecdotes about Lillehei, Shumway, Lower, Debakey, and Cooley – legendary pioneers in heart surgery, whom he knew at the end of their careers. I think between my idea about the NG and listening very attentively for 30 minutes, I may have repaired my past blunders. Now to keep from slipping for the next week!

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