I was going to stop blogging entirely, but my mother wouldn’t stand for it, and I discovered I’ve developed an intractable habit of telling stories in my head, and without this blog, there’s no one to tell them to. So I guess we’ll keep going for a while. (When I found myself seriously trying to talk medical students out of going into surgery, that was really full circle. . . but maybe there’s something beyond the circle.)
Vascular surgery is the most complicated inpatient service to try to run. For one thing, trying to doppler for pulses takes a lot longer than checking to see whether people have significant abdominal pain or not. For another, the patients have all the usual surgical issues (wounds, getting out of bed after surgery, pain control, post-op fevers to worry about), plus a lot of medical issues. It would be unbearably unwieldy to consult medicine on all these patients, who usually are well looked after as outpatients by doctors who don’t round in our hospital, so the junior house staff get to keep an eye on the medical things: blood pressure, blood sugar, etc.
And then there are the things peculiar to vascular surgery: which patients are on aspirin, which ones need plavix (in many cases only riskier, not more beneficial), and which ones are supposed to be on both, as a step below coumadin; which patients are on a heparin drip, which ones need it stopped for surgery tomorrow, which ones need it started the day after their surgery not the day of; which patients aren’t on heparin at all, but lovenox instead; who needs lovenox arranged for home (it’s tricky to set up with the insurance companies; I love case managers); who is on coumadin, and of those, who is getting 2mg, and who 10mg, who’s at a therapeutic INR, who’s overshot and skipping a day (but don’t forget to write for it tomorrow), and who’s still slowly working up to the right INR. . . If you get any of those mixed up, the patient will either start bleeding catastrophically, or else clot off their leg; and of course they could do either of those anyway, even if you get it all right.
I got to do a small case the other day, and after some bleeding developed, I was internally congratulating myself for not panicking, and not simply staring at it, but quickly putting my finger on it, till we could get suction and forceps and a stitch together. Afterwards I realized that my eagerness was overkill, since the blood was only pooling out of the incision, not shooting at the ceiling; which means, for vascular surgery, it didn’t count as real bleeding at all.