in the OR

Back in the OR at my own hospital, I realized several other things I’d been subconsciously missing at the children’s hospital: besides a mutual recognition with the techs, nurses, and anesthesiologists, and material things like scrub sinks working the way they should, trash bins sitting where they should, and light handles that fit the way they should, I’d missed the attendings caring what I did. At the other hospital, I was very much a  migrant: they put up with me for six weeks, and now they’ll never see or hear of me again. As long as they kept me from doing any positive harm in that time, they could care less whether I learned to operate well. Here, the attendings know they’re stuck with me for several years, and I think even beyond that pragmatism they’re committed enough to teaching that they care about my learning.

This manifested itself in the attending criticizing nearly every move I made for two hours. The minute we started draping, it suddenly hit me that this was a much more complex operation than the appendectomies I’d been doing for the last several weeks, and I nearly froze. It took an effort to do simple things, things this attending long since expected me to do quickly and semi-smoothly. Him telling me to loosen up didn’t really help, but after ten or fifteen minutes I started to get in the swing of things. Back to the usual pattern of him stopping every five or ten minutes to explain why my actions were completely counterproductive, stupid, harmful, or simply inelegant.

That may sound like a complaint, but really it was good (and even better when done with) to have the attending take the time to talk about technique. This attending likes to repeat, “You should do every case as if the patient was your own mother.” Personally I find the metaphor a little disturbing, but he’s teaching professional attention to detail at all times.

At the end, I found that in the middle of all the stress and criticism, he was actually letting me do more than he ever had before – which was why he found so many things to teach about.

And that leads to a last humbling conclusion. I have so much more to learn about surgery before I will even begin to be a surgeon. Now I begin to get the hang of where an operation needs to go, what the next step needs to be; but on my own, I go so slowly, hunting and pecking my way through. I don’t have the confidence in my plan to jump in, and push, cut, tear, burn things to get where I’m going. And that’s what it is to operate: to know so thoroughly where you are, and what needs to be done, that you can cut without hesitating.


I feel sorry for the OR team that got stuck working the same night with me. We had a case of perforated appendicitis, the kind where you start regretting the decision to operate the minute pus starts oozing out of the first incision. (Note to ER doctors: unless the patient has a creatinine of 3 [indicating real renal failure] never ever ever do a CT scan without iv contrast (ok, unless you’re looking for kidney stones); and there is literally no excuse in the world for not giving oral contrast to a patient over the age of reason – appropriate use of antiemetics should enable the patient to get at least a modicum of the contrast down, and some is better than none. For the non-medical readers, iv contrast is invaluable for demarcating abscesses, which are characterized by a vascularized wall, and no blood flow inside. It also helps to diagnose dozens of other surgical conditions, including mesenteric ischemia, ischemic gut, and small bowel obstructions which need an urgent operation (as opposed to the ones that can wait). Oral contrast is necessary to show which round objects are intestine, and which could be something else, like an inflamed appendix or an abscess. Not having contrast is like trying to peel potatoes in the dark – a waste of time and radiation.) (Note to self: next time, when the patient has diffuse peritonitis on exam, you should ignore the worthless noncontrast CT scan which may or may not show an abscess, and go with your clinical diagnosis of a perforation that’s had time to spread.)

(Appendicitis complicated by perforation and an abscess ought to be treated nonoperatively, because surgery is too difficult and risky in that setting. Like many other medical pearls, I didn’t quite believe that one until I proved it for myself. Someday, I’ll stop reinventing the wheel.)

It’s not that I did the case badly, just very very slowly. I’m doing better at getting the laparoscopic instruments where I want them to go, but things take twice as long when I drop everything I pick up, and have to grab it again and again before I get a grasp that works. However, as the attending observed, since there was already pus everywhere, things could hardly get any worse. . .

Better luck the next night, I guess.

It’s a good thing I have to admit so many kids with appendicitis and non-appendicitis, because I need more work on laparoscopic appendectomies.

This became abundantly clear last night when, two-thirds of the way through a case, the attending commented, “Do they do laparoscopic appendectomies at your hospital?”

“Well, yes sir, they do, but I haven’t gotten to do any there yet.” [so the fact that I seem to have two left hands is really not my program’s fault] 

The appendix being at the other hand of the abdomen from the stomach and gallbladder, which is what I’ve mostly worked on (or tried to) laparoscopically, appendectomies feel like working upside down and backwards – and it shows in my random sweeps which usually don’t even get my instrument onto the screen, let alone do anything helpful to peel back the inflamed tissue and expose the parts that we need to be working on.

Peds is good. The babies are cute. Actually, this is a problem on rounds, because I would rather play with the babies than pay attention to the details of calculating their feedings or TPN orders.

The anesthesia part is amazing. Anesthesia for these tiny babies is incredibly delicate. The ET tubes for the smallest babies are about the size of an adult venous introducer. . . And for the older children, the finesse with which the anesthesiologists talk them into staying calm during the trip back to the OR (admittedly, with the help of versed) is impressive. For adults, induction of anesthesia is usually performed with an iv agent – quick. For kids, though, they avoid putting in an iv until they already  have them asleep with an inhalational agent – which means they have to be bagged the whole time an iv is being found on their tiny hands or arms.

Not to mention the matter of waking up: In adults, you like to get some definite responses to commands before actually pulling the tube out. For kids, there’s no way they’re going to do anything coherent while still coming out of anesthesia, so the anesthesiologists have to just pick a moment when they think the child is awake enough, and doing some spontaneous respiration, to pull the tube out, and wait to see what happens. After all, they’re small, and easy to ventilate by hand if they need a few more minutes to wake up. (Some anesthesiologist will no doubt come by and explain that there’s a lot more detailed calculation involved. Either way, I’m impressed.)

The OR and ICU staff are coming to the conclusion that I’m crazy. They can’t tell why else I would spend the day with a stupid grin on my face, when all they can see is that I have some of the sickest patients in the ICU, the worst cases on the schedule, get no help with scutwork from the more senior residents (some seniors help, some don’t; mine don’t), and have attendings whose form of praise (I’ve decided) is to come up with more unique phrases to explain how incompetent I am. (I know this because he was doing it today while I was doing a simple job perfectly, so I think he really meant it was nice to have me around so he could say things like that.)

It seems a little embarassing to keep explaining to everyone I see that I’ve been doing more surgery in the last few weeks than ever before, and more complex. After all, it’s hard to admit even to the OR nurses that this is my first time at nearly all these procedures. I’m perfectly happy to have an OR schedule crowded with hard cases, because that means some good ones trickle down to me. I don’t mind staying late nearly every night, because it means I’ve been in the OR most of the day, and have to stay late to catch up on people.

The sick ICU patients are not so great, but at least they’re all still alive, which is more than we expected of some of them. And them being sick is not my fault, not by the remotest stretch of anyone’s imagination, so I can take care of them without feeling guilty for them being in the ICU. (As in, if I had paid more attention, would I have noticed some miniscule fact that would have made a difference in their care earlier.)

Posting has been a little light due to a recent transplant marathon: one transplant after another, starting in the afternoon, and concluding the next morning. The best summary would be to say, that after doing so many of one procedure in a row, I knew the steps in my sleep – which was good, because that was what it was close to by the end. . . I still wasn’t able to satisfy the attending, who seemed to want to know why, twelve hours after he’d first told me I needed to improve a point of technique, it still hadn’t been corrected. (Saying, Sorry, right now I’m lucky to be standing up straight, and doing something at least functional with the instruments, can’t think straight enough to change habits right now, did not seem like a good idea.) (I sent the poor medical student to bed some time after midnight; he also seemed to find that irrational, but neither of us had enough energy to discuss it in detail.)

I got my fill of “continuity of care:” admit one patient, scribble some pre-admission orders (stat labs and induction immunosuppression) for the next one, run down and do the back-table on one kidney, go meet and examine the second patient, do the first case, write pre-admission orders for the third, back-table the second kidney, go check that the first one is still making urine, look at his chest x-ray, and continue. . . Then, the day after, even though the attending and I rounded before leaving the hospital, so I technically had handed over coverage of my patients to an on-call intern, neither I nor the nurses felt like leaving the intern in charge. If I didn’t wake up every hour to call and check on someone, they were paging me, or else had stumped the intern and he was calling to ask me. . . Eventually I gave up on sleeping and tried to get some chores done instead. I hate that feeling of waking up, and not being able to remember which nurse I had intended to talk to this time, or whether the fluid bolus I’m thinking about is something that has already happened, or that I still need to order. I keep intending to take a paper with me and write notes, but around the time that the difference between am and pm disappears, the coordination required to get a paper and pen in the same place also drops off. The significance of low urine output, however, sticks around.

It’s taken me 16 months of residency to find out what surgery as a profession is really like. I need to figure out who in the hospital has coffee available at midnight before trying that one again. Otherwise, give it another day or two, and I’m up for it.

Some friends at church asked me what my favorite kind of surgery was. This blog has given me the bad habit of being frank about my job, so I said, “Vascular surgery, because if you miss a stitch, blood shoots up at the ceiling.” They were rather horrified, and began relating how they had been traumatized by dissecting fetal pigs in high school or college. 

Note to self: There is a reason that most doctors never talk about their profession outside the hospital or clinic. From here on, even if people ask pointed questions and seem to be genuinely interested, I will say nothing. I will be a monument of discretion (yeah, right).

Which brings me to my least favorite part, at least of transplant surgery: dissecting out the external iliac artery and vein using electrocautery. This works out to the attending surgeon isolating pieces of tissue which he thinks do not contain any tiny blood vessel branches, and then me bovieing through them. So I’m holding one end of a 9″ long bovie, manipulating the other end deep in a hole, 1mm away from two very large blood vessels. This strikes me as an extremely bad idea. I still don’t know 1) how I get up the nerve to do it every time 2) how come I’ve never hit the wrong thing yet. But I guess that’s the whole point of surgery: cutting small things, surrounded by larger objects which it would be dangerous to cut; if you don’t get comfortable with that, the operation takes twice as long as necessary, to the danger of the patient and the annoyance of everyone else in the room.

The other option is perhaps safer, but not easier for me: right-angle clamp around a tiny vascular branch, pass two silk ties around it, tie off on both sides, and then cut in the middle. Which works out to 1) only 1 out of 5 scrub techs ever seems to grasp the concept of handing ties in a way that is of any use to the surgeon who only has one hand free for it; the attending doesn’t see the antics they’re getting up to, and not-quite-silently blames me for not completing the maneuver faster  2) the attending gets to critique my handling of the ties, and then my method of tying, over and over and over again. Which means I learn a lot, sure. . .

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