I had an interview yesterday, but I’m not going to discuss interviews or other programs at all on here. We’ll just say they’re happening, and life is interesting on the road. . .

Today, back in surgery with Dr. Ashley and Bob, the third-year. No intern – we were both delighted. Three total shoulders were scheduled. The first patient had a very weak and deficient glenoid fossa, so after a good deal of frustration on Dr. Ashley’s side, compounded in equal parts of difficult patient and medical students not doing exactly what he wanted with the retractors and suction, he ended up bone grafting around the glenoid implant, and closing him up, planning to return in three months to see if the graft is taking, and maybe replace the humeral head at that time. I was astonished at the concept of leaving a patient with only half a joint, and keeping the limb totally immobile, for three months, and then looking to see what can be done next. Well, I guess the shoulder was in really bad shape to start with, so there weren’t many options.

The second patient went more smoothly, except for a couple of hairy moments where there was obviously an arterial bleeder somewhere in the depths of the excavation between shoulder muscles, but we couldn’t see where it was, and I couldn’t suction enough to clear the view. Eventually it became more obvious when a fountain shot out over the three of us (making me very glad for the helmets we were wearing), giving Dr. Ashley the opportunity to clamp and bovie it. I’m not sure whether it was a compliment to us, or a sign of desperation, when Dr. Ashley asked for our recommendations about how to stop the bleeding. . . (This whole episode only lasted 1.5 minutes, so no one out there gets the wrong impression about Dr. Ashley’s competence.) He let me close the last part of the skin. I learned: 1) I have no idea why orthopedists put so many stitches so close to the skin surface; it gives a very messy scar, and I can’t get the needle into the contortions needed to do horizontal mattress sutures next to the neck – especially with a junior student watching and asking questions about technique! 2) Holding the skin so someone else can put in staples is more difficult than it looks. 3) Junior students asking me questions make me nervous. After Dr. Ashley asked us three times if we hadn’t pulled out the drain, the nurse explained that she had had the misfortune to do so last Saturday. . . we didn’t pull it out at all today. . .

The CRNA invited me to intubate the first patient, and I couldn’t quite get, and the anesthesiologist was upset because the case was already late, etc. The CRNA and I rolled our eyes at each other; we are old allies now. He compensated by letting me stand by his shoulder and explaining to me every single step for the next two intubations, and showing me the vocal cords when he found them. We’ll put that down as another factor in my failure: I forgot what the vocal cords look like. (This is awful, isn’t it? I want to be a surgeon, and the last two dozen times I’ve tried, I can’t get an intubation.) So now I know what it looks like when you do it right. Maybe tomorrow. . .

The third patient was the only “standard” shoulder; the others were reverse joints, where the ball is put into the glenoid, and the socket is fitted on the humerus. This is for people with severe rotator cuff disease. The standard procedure calls for dividing the subscapularis tendon (anteriorly) and then sewing it back together with heavy sutures through the humeral bone after the prostheses are in. You can tell where this is going. I was holding the retractors quite still, and Dr. Ashley got me with one of the huge needles (four inches long!). I pulled off the top glove, and he and I looked at the lower glove, and couldn’t see a break in it, so he proceeded. Privately, I didn’t see how it could feel so sharp without having actually touched me. But I had been struggling all day with a half-dead voice, and inside those space-suits I had to repeat any remark three times to be understood. . . He let me put in all the subcutaneous sutures, and take care of the stapling and dressing and all. When I finally got to take off the sterile suite, I could see a definite hole in the lower glove by stretching it hard, and my hand had a tiny scratch. I figured the only thing might be to give the patient more antibiotics, but after Wednesday’s episode, there was no doubt about what to do. I ran after Dr. Ashley and found him just before he left that part of the hospital. He smiled at my explanation, and said the patient had plenty of antibiotics, since he routinely gives them for 24 hours post-op anyway. But we both knew the point was that I told him, not that anything major happened.

(And I refuse to go sit in the ER and fill out paperwork because of a 1-mm epidermal scratch with a sewing needle, as opposed to a hollow-bore needle. So there.)

(Dr. Ashley has some more cases tomorrow, so I may post about those. If not, my family is going out of town. Happy Thanksgiving, everyone. And I challenge you all to say it like that, Happy Thanksgiving! The day is not about turkeys, and we are not giving thanks to turkeys – and say that to anyone who tells you, Turkey day.)

Advertisements