Second patient to be presented in the “mortality” section of M&M this morning started off, “F.G., 81yrold, male presented with partial small bowel obstruction. Actually, he came in three times over the course of five or six weeks. The first couple times he was treated with an NG tube, and his symptoms improved.” At that point I woke up. The initials clicked, and I knew I’d seen this guy: the first time he came to the hospital I was on the emergency surgery team, and helped work him up. And later, at the very end of my surgery rotation, I helped the very new intern on call figure out his complex chart. Both times, his xrays were stunning: marked distention of the small bowel, obvious and pervasive air-fluid levels. Bother it, I hate it when someone else lets “my” patient die.

At one point in the dissection of his death, one of the attendings remarked, “I don’t understand why we didn’t do surgery earlier. Look at these xrays. Even a medical student could tell you this guy needed surgery.” Yeah. Uh-huh. I just didn’t say it out loud, back then. When I saw him and one other elderly person being treated with “NGtube and NPO,” I just figured I must have misunderstood that old surgical axiom, “Never let the sun rise or set on a small bowel obstruction.” I will now take that one seriously. And I will make a note to always, at least once, say what I think should be done with a patient; at least after I graduate. Apparently every now and then I have the right idea, and I’d rather make idiotic suggestions a number of times, than every now and then miss saying something vital.

So, the third or fourth time this guy came, somebody decided to operate on his hernias, and see if that helped. It did, but didn’t show any reason for the obstruction. A few weeks later he came back, this time with a strangulated internal hernia. After a complicated post-operative course, involving numerous trips to the OR, he eventually became floridly septic, and his family agreed to withdraw care. So the attendings this morning were left to suppose that if he had received a definitive operation for bowel obstruction the first time he came to the hospital, he might not have developed all the later problems.

Three cases today. I got to help suture with the last two (yes, that’s the only thing that matters to me any more about operations; I stand there daydreaming about the day when I’ll at least be on the other side of the table, able to see what the attending’s doing, if not actually help, and the only part where I really come awake is at the end, when they’re sewing the fascia closed, and I know the skin is next). One of the attendings stopped to make me use both the needle-driver and the pick-ups correctly, and I was surprised to find that it went much faster that way. Ha. Imagine that – it’s faster to do it correctly.

I have also been realizing that, as a surgical resident, you have absolutely no right/need/obligation to operate, or even enter the OR, until your third year. Anything before then is purely by the grace of your chief. After observing the second year resident very meekly go to clinic all week, and be thrilled with the one operation a week that the chiefs throw her in return for all her work on rounds, I finally figured that out. This is going to be a long two years. . .

After the scrub nurse today ripped four pairs of gloves, dropped three objects on the floor, and finally stabbed her arm with the scalpel, we all begged her to go home before the last case, a patient with Hepatitis C. Employee rules required her to leave, so we didn’t have to discuss much, except exactly how the surgical resident was going to repair her arm. The attendings offered the resident and me not to scrub on that last patient, but the resident wasn’t going to miss a chance to do something, and I figured I won’t be able to avoid all of them, so I might as well get started double-gloving.

(Needless to state, all names and other patient details have been changed to protect privacy.)

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