Sunday, November 18, 2012

Vascular Surgery...aka sophisticated plumbing

The morning cases with Dr. Snarky Surgeon were cancelled, meaning I and my rotation mates schleped all the way down to Chicago Hope Hospital no later than 7am for zilch. Nada. Nothing. Lovely
At almost 2:00 pm I scrubbed in a mass excision case with Dr. Simon. Toward the end he said "Let the student close." And handed me a suture. The surgery tech asked if I wanted her to start it for me, but I said no, I'd prefer to try it myself. I've been practicing on banana peels and pig's feet, and have worried myself about how joyously I tie my trash bags with surgeons' knots...but I was still super nervous. Trash bags don't breathe and kick. Either way, I'm sure it wasn't the world's best suture job, but I finished before the surgery tech finished closing a wound of the same size. I was pleased with myself probably more than I had justification for, but hey, I just did my first suture from beginning to end. 

Later, a patient comes in with three week history of a blood clot in the R foot. Vascular surgeon, Dr. Simon adds this to the schedule and starts to do his thing. This surgery started late in the afternoon and this type of surgery typically lasts 3+ hours. None of us scrubbed into the case as typically he doesn't bring students into his cases. Four hours later multiple clots multiple inches long have been removed from the patient's arteries.  Look here for a description. It's basically a really small plumber's snake with grave ramifications should things go wrong. Patient is sent to recovery and back to the floor and everybody goes home except for the on call person.
Throughout the course of the procedure I banged my head at least five times on the lamps. I'm over six feet tall. The tech is maybe 5'5 (maybe) and the surgeon was seated. I'm 6-foot-not-5'5.  I was standing behind him, in between the lights, and was constantly re positioning myself to stay out of his light, in view of the procedure and they were constantly adjusting the lights as they were moving up and down the leg. What ends up happening is I smacked my head every time I turned around, in one case looking for the blasted light in order not to smack my head on it. I was getting rather embarrassed and was worried that Dr. Simon was going to ask me to leave. 

Dr. Simon rounds on said patient and does a Doppler test on the posterior tibial artery. He gets a result that does not please him. The patient has very faint posterior tibial and dorsalis pedis pulses and the patient's leg is cold. Dr. Simon sends the patient immediately to the OR. I was wandering around the OR with my rotation-mates dividing up the day's load when one of the surgery techs came up and said "you should scrub in with Dr. Simon, he likes you." So I stick around and help the patient in the room, get everything set up, and ask the doctor if he could use an extra set of hands with this procedure. He said "sure." So I scrubbed in. 

Since I'm on that topic, permit me to ramble for a moment about what "scrubbing in" entails:
- Placing a mask on your face, usually with an eye shield. For reasons to be explained later I put a shield-less mask over my mouth, and turn the face shield upside down and tie it around my forehand, resulting in it hanging down from my face. The face shield mask is designed to be a mask and a face shield in one, but I've yet to discover the spell that makes it function properly.
- Literally scrubbing your hands, fingers, elbows, arms, and underneath your fingernails with soap and very hot water. After that you cannot touch anything, and there are special sinks designed to facilitate this. 
- After "scrubbing," you proceed the room with your hands in front, ready to kill anybody who comes near you for fear they will touch you and require you to scald your arms again. You wait until the scrub tech (scrubbed in himself) opens a gown and you put your arms in the sleeves. The gown ties in back, which somebody else does for you. The scrub tech then opens a glove and you place the right hand in. You then use the right hand to help hold the left hand glove and in goes the left hand. If the procedure is going to be particularly bloody a second glove, half a size smaller is put on as well. The gown then needs to be tied a second time. The strings are held in front by a piece of cardboard. You take the first string in your left hand, hand off the cardboard containing the second to another person, then twirl around and find the string waiting for you ready to be tied. You tug the string from the cardboard and it gets thrown away, and you tie the bow at your side. At that point you are sterile, and I find the best place to be is in the farthest corner from the action possible, that way nobody bumps into you and makes you repeat the process again. When the table is sterile you go to the table, ask where the surgeon wants you, and place your hands on the table and do not move until told. Dr. Simon calls it "Simon Says" (hence his pseudonym). 
- Five minutes after you scrub in for what is at least an hour (and almost always more) your nose, eyebrow, eyelash, or scalp begins to itch. Madly. And you can't do a thing about it because the mask and your scrub cap aren't sterile. You just have to grin and bear it. 
- The few times I've attempted it, the blasted all-in-one face shield mask fogs up the first chance it gets. More often than not I've had to ask someone to rip off the shield and place another one on, upside down, in the aforementioned manner. Now I just spare myself the trouble and put two masks on. It makes life much less complicated.

So, we get started in Thursday's surgery. What starts off as a thrombectomy quickly spirals into an expletive-filled day of frustration. Two cuts become four, become six, become nine until one entire side of the patient's leg is split open and looks like hamburger meat. During this point I learned about a bear claw wound and how the skin in between the wound dies due to lateral perfusion of the skin. This was relevant (so asketh the doctor) as Dr. Simon was making multiple incisions...none of them parallel. The thrombectomy doesn't work, so Dr. Simon proceeds to bypass from the popliteal artery to the anterior tibial artery. Still the pulse and doppler is weak. He attempts to enlarge the vein with multiple catheters...nothing. He gets pulse and flow (at one point the flow shot me in the face, of course I was wearing glasses, so I was face-shield less. Nothing like hot, gooey blood on your face...) from the artery, but gets nothing in the foot. He isn't pleased. Around noon, during all this, I notice that he isn't even done cutting, and closing these wounds takes at least an hour, so I set myself to the fact that I'm probably not going anywhere any time soon. Just as well too, because this was a really interesting case.
Finally he finished the bypass, saying there is nothing else he can do but close and pray. We close and I find that the remainder of the day's cases have been completed and make a mad dash for my car.

The next morning Dr. Simon has another case on the board. I figured since I had scrubbed with him the previous two days I would give my colleagues a shot at working with him. I start the morning with a circumcision, and basically am a glorified scissor holder for that one. Either way I usually learn more about things other than the case when I scrub in, so it's a good opportunity.

After that case I had to use the facilities, and I'm in the locker room when my phone rings. It's my clinical partner, telling me that Dr. Simon and Egyptian-Assistant are looking for me. And want me in the case with them this morning. A good feeling, no? At one point I bumped the table and he says "that was almost really bad." And then proceeds to tell me a story about how he did something worse when he was in residency saying "see, it wasn't the worst thing you could've done.'' One thing I like about Dr. Simon is that as long as you don't make the same mistake twice he doesn't get angry. We're expected to make mistakes. How else are we to learn?  It's repetition that he dislikes. So I make quick note of anything and everything he tells me and do my damnedest not to repeat it! This particular case was a popliteal posterior tibial bypass, and on this day everything went routinely. The doctor was in good spirits, with Billy Joel setting the mood, he was singing along most of the cast. Afterward there were no cases, and I waited for a while since I was on call, but nothing came in. A friend had an extra ticket to see Les Miserables, so I went and it was a great show.

8am I get a text from a friend who was on OB call, at the hospital for OB surgeries. He informs me that the student scheduled to be on-call did not show up, that there was an emergency thrombectomy (again!) on the schedule, and that Dr. Simon was already at the hospital and not looking happy about having to be there. Having already had an a rather unpleasant encounter with Dr. InCharge about people not showing up, I immediately texted and called the person on call at 8:05. Nothing. I jump out of bed and into some clothes, and make a beeline for the door. Awesome Partner lives across the street and has been informed as well and tells me she's running to her car as well. I tell her I'm already downstairs and to just relax, I'll take care of it. She says "I'm the student coordinator and I'm going to get yelled at for this. I have to be there. Pick me up!!!" I said yes ma'am.

8:56: I finally get a text from the on-call student saying she's just getting in the shower. I tell her to just stay at home, I'm already at the hospital and scrubbing in. Another student scheduled for afternoon call says she is on her way in, but she's an hour away in the hospital in the suburbs.

12:30: The case is not going well. The doctor cannot get a pulse in the patient's foot after multiple thrombectomies, opening up all the incisions we spent an hour closing the day before. Lovely. He says it might go into another bypass. I look after at the Assistant and say, "I haven't eaten. If he's going to go into bypass can I go eat something quickly?" She knew I wasn't supposed to be there, I told her I made a mad dash to the hospital, and she said go eat. The afternoon call has arrived and has asked to scrub into the case as she hasn't seen many of his surgeries. I say bless you. And make sure everything is ok with Dr. Simon and the assistant. The asistant claims that she has told me to go home, and that they're closing. I go home.

Ten minutes later I get a text saying they're going to do another bypass to the anterior tibial artery because after closing the initial incision there was still no pulse in the foot. Lovely.

And that, folks, has been my week.

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