Ok, I’m back online. This rotation is nearly over, which is a good thing, because honestly I’m more depressed, miserable, and angry than I’ve been in residency so far (except maybe on trauma; and that was made more tolerable by having friends around, residents and nurses I knew and trusted). Now I’m trying to figure out what to say when I get back “home,” because several of the residents were teasing me that I’m so optimistic, but the peds rotation would destroy me. They were mostly right; I’m just hoping it’s not permanent; and I don’t want to admit it to them. There were three rotations of second year that I knew would be absolutely horrible; one down (almost), two to go.
Anyway, I’ve been remembering the things that made me go into surgery in the first place (a decision that I’m not up to defending right now, just hoping I’ll feel better about it once I get away from this place). One particular story I remember because at this hospital we had a child develop a wound dehiscence after an abdominal surgery. Supposed to be pretty rare in kids, and the M&M on the subject was protracted, to say the least. A dehiscence is when the fascia (not just the skin) comes upon. There are two main reasons: you didn’t sew it properly to start with, or the patient’s tissue, for various reasons (debilitation, radiation, steroids, infection, to name a few), is so weak that it simply doesn’t hold even the best suturing.
I was on call on ob/gyn, and in between the deliveries and an ectopic pregnancy case, the team got called about a patient in the ER. She’d had an abdominal hysterectomy about a week previously, and had gone home shortly afterwards, apparently healing well. She dehisced at home, fortunately only to a minor degree, and came in to the hospital. As a medical student, of course I was fascinated, and tagged along the whole way; but I was also frustrated by the OBs’ response. The intern went and looked, and paged the senior; he went and looked, and called the attending. She didn’t believe him, and went to look too. At that point they agreed that they supposed it was a dehiscence, and called the surgeons to ask for advice.
I’ll never forget the surgery intern (who was after all tall, handsome, clever, and only not cocky because he was smart enough to warrant his own confidence). He strolled in, looked at the wound briefly, and remarked, “Yes, it is dehisced, sure enough. You’re taking her to the OR, right? You don’t need us for anything, do you?” The OB attending agreed that this was her plan, but insisted that the intern bring his senior, and even the surgery attending, in to look at things in the OR. Her explanation also sticks in my mind: “I never saw anything like this, even in residency. I’m not sure what to do with it. And maybe we ought to run the bowel [surgical speak for starting at one end of the small intestine and looking carefully till you get to the other end, to make sure there are no injuries or other anormalities], and I forget how to do that.” So the attending surgeon, being dragged out of a sound sleep (they were required to take in-house call, but counted on the seniors to shield them from any disturbance except a trauma requiring a laparotomy), came in to the OR and explained to the OBs that when the fascia comes apart – you should sew it together again. The end. And if you want to run the bowel – you start . . . at one end. . . and proceed . . . to the other end.
I’m not trying to make fun of the OBs, because they were overall good at what they did (that attending was one of the weakest), and I understand that dehiscences would be much rarer in a population of relatively healthy women (overall younger than the general surgery population) having elective hysterectomies. But to a medical student, it was noteworthy. Even then, several months before I did my surgery rotation, and got swept off my feet, I started to think that I’d rather be sure of the basics.
I still hate this rotation. But I expect I would have found at least one occasion to be equally miserable if I were doing ob/gyn, as I originally planned.
I ought to tell another story, where the joke is on us. We had a pregnant woman staying with her sick child at the hospital. One evening, the nurses called the fellow in a bit of excitement: the mother was having contractions, with increasing frequency. He ran upstairs, and became quite excited himself, and eventually with great commotion hustled the lady off to an adult hospital with an OB ward. Myself, I regarded it as less of a problem. First, unlike the fellow, I’d known she was pregnant prior to that night (just by looking; I guess he didn’t notice). Secondly, I considered that with her contractions still 8-10 minutes apart, she was unlikely to deliver within half an hour, which was plenty of time to arrange transfer (second pregnancy; maybe I was being too pessimistic). Thirdly, I privately thought it would tremendous if we did have to assist with the delivery after all. Of course, that was the thought that was really upsetting the fellow.