Le fin surgery

Yesterday marked the last day of surgery. Because God does have a sense of humor, there wasn't anything to do until 2pm. My rotation partners and I literally sat around and did nothing from 10am when we finished our exam and the pediatrics grand rounds we were invited to until almost 2pm. While we were sitting there (I actually fell asleep for a good half hour at one point) we were hearing rumblings about a small bowel obstruction that was put on the schedule. Grand. Just what I needed on the last day when all I wanted to do was get out of here on time.

Luckily the doctor showed up on time (Shock me!) and the surgery started on time (Please pick me up off the floor). I felt completely superfluous in the surgery. I had scrubbed with this same doctor the day prior and actually got to get my hands dirty. Not today. The first assistant wasn't really needed either. All the doctor did was run his hands along the entirety of the small intestine, lop off the obstructed segment, and sew it all back up. Mostly a one-man job. I just kind of stood there like a bored idiot, trying to think of questions, no matter how obvious the answer was, to remind the doctor that I was indeed there, and not just an ugly piece of art propping up the table. The only thing of real interest to me was the fact that this was the patient's sixth surgery for an obstructed bowel, and her abdomen was covered in flowery, vine-like tattoos. What a pleasure to close that back up.

So now surgery is done. I enjoyed the actual operations and procedures, but I can unequivocally say that I did not enjoy the very unpleasant lifestyle and environment that the high-stress OR fosters. I wasn't looking to go into surgery before I started this rotation but I did enjoy it more than I thought I would. I must say I grew tired very quickly all of the unnecessary and at times unprofessional drama and pot-stirring instigated by one individual in particular who seemed to have an unwavering need to make us feel as insignificant as possible. This same individual is also the type of person who when she feels is correct will say anything and shred you alive if you do not agree with her. I felt like I learned a great deal, not just about surgery, but about the associated clinical and physiological aspects of the cases that I had the opportunity to work.

After our last day, most of my rotation partners joined for an evening of celebration. I must say I enjoyed myself immensely from the conversation, to the food, to the company. It's not often I'm in a group of people with whom I feel so at ease and on the same page. We started our evening in Wicker Park, and (somehow) ended the evening at the Hancock Center's 96th floor lounge. This was a first for me, and I enjoyed it immensely. 

The Day Just Got Better

Thought the events of yesterday morning and the Coffee Caper were ridiculous and hillarious, the afternoon almost equaled it.

Dr. Simon (one of my favorite surgeons to scrub with) had a late afternoon AV graft case. After the patient was draped, the field sterilize, and Dr. Simon and Egyptian Assistant scrubbed in, Dr. Simon looks at the patient's arm and proclaims that they patient has not been sterilized properly/to his satisfaction, and that the entire setup must be repeated. Having irked half the surgery staff he proceeds to stand up, and turns around and walks straight into the cart that contains all of his sterile instruments, sending a bowl full of water and several vascular clamps crashing to the floor. He looked very hard like he was trying to blame somebody, but couldn't, because it was obviously he.

"This cart looks like it's missing a wheel!" The cart clearly had four wheels...Dr. Simon then left the room to wait for the patient to be redressed. Egyptian Assistant then looks at me and Awesome Partner, points to her and says with a smile, "You, you can come in. But he, he has to go home. Go away!!! He cannot come in! This never happen before! Ever! He is jinx!!!" It's understandable. Nearly every time I've scrubbed with Dr. Simon something complicated happens. Yet he continues to let me scrub in...

And that's a true story.

Patient of the Day!

My surgery partners and I were in the student lounge this morning along with the anesthesia and GI students, waiting for the morning's cases to begin. It was scheduled to be a very light day. 

Out of nowhere, a gentleman walks into the room, very quickly. Not really an unusual occurrence as from time to time patients miss the giant sign that says "Secretary"...Instead this patient proceeds to grab my partner's coffee that was on the floor, tore off the top, and proceeded to down an entirely full cup of scalding hot coffee in three gulps. This being a hospital, we were all a little confused and initially concerned that something my be wrong with the patient, like he was choking, or having a panic attack. The patient ignored all our questions and concerns, in English or Spanish, and continued to voraciously gulp down Ben's coffee, all the while we stare incredulously asking ourselves What exactly is going on here?? They didn't tell us about this in medical school.  After the second gulp, we hear somebody from outside the room yelling out his name. "Stop that!!! Not again!!" And then nonchalantly telling us that he does this all the time, stealing other peoples' coffee, and voraciously consuming it. Totally normal! The patient then bolts out of the room, frantically searching for someone else's coffee. My partners and I can do nothing but sit there with perplexed looks on our faces before what has just happened registers. When it does the looks of confusion turn into smiles and fits of laughter.

It would be seemingly harmless, were the patient not scheduled for a hernia repair.

Vascular Surgery...aka sophisticated plumbing

Wednesday:

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. 

Thursday:

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.

Friday:
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.

Saturday:
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.

Dream

I'm starting to have really odd dreams about being in the OR. Two nights in a row I've had this dream where I need to be scrubbed in (sterile) but I'm not needed, and all I want to do is go to sleep (it's about 2am when this is happening) so in my dream I have someone pull the covers over me and I position my hands such that they're still sterile. A few minutes later I wake up uncomfortable and grumbling at myself for being an idiot.

Gotta love it when you arrive at 7am for a day that doesn't have cases until almost 2pm. Coming in any later just isn't an option, so you chew on it, bring a book and just accept your lot as a peon. To stave off sheer boredom I went wandering the floor, chatted up my IM attending (who gave me an A+ and a stellar review) and learned a few things about Pulomnary emnoli, DIC, and "poor prognosis diagnoses." I am actually quite glad I went wandering, because it beat sitting around not doing anything.

Later, I was able to scrub in on a mass excision case. The doctor said "let the student close." So from start to finish I closed. I was ridiculously proud of myself.

Later in the day began the hours-long vascular marathon of popliteal embolism removal. It was so epic I was called to wipe the doctor's face free of blood...The surgery lasted almost four hours due to a host of complications and annoyances, such as luckyone banging his head no less than three times on the overhead lights. Blast ye short people!!!

You Know You're in Medical School When...

...You use an expired suture kit to sew on a button. Yeah, I used double and single handed knots, too!

Today's Awesome Surgery

Secondary to a pneumothorax, and emphysema, I was able to scrub in a thoracotomy. We removed the part of the upper lobe of the right lung that had blebs the size of golf balls. It was intense!! I loved every minute of it. I had never seen lungs in a living person before!

Eavesdropping

It's amazing what you hear when people don't think you're listening. For instance, the first week of my ortho float the very Mexican Medical Assistants had no clue that this güero understands Spanish well enough to hear you slagging him from the other room. Obviously it doesn't dawn on these ladies that medical students become their bosses--shortly.

Ortho/Musculoskeletal Clinic

This is my last full week of ortho clinic. Because I'm nice and so are my rotation partners I've offered to step in and cover for them on two days when they need to be out of town. Because I've already done the rotation, two extra days in ortho clinic won't be a big deal. But I am looking forward to being done with it every day. It is long, intense, and has been a great learning experience, basically because we have been thrown into the deep end of the pool and told to sink or swim. So we started swimming. I think that's the best way to learn. The attending has laid out his requirements, and you do it. See one. Do one. Teach one. He's very hands off. If he doesn't want you to do it, he won't let you, but other than that it is basically we, the students, who are actually "practicing" medicine in the clinic, and the attending usually approves our choices. Maybe we're learning something??

I've learned how to do knee injections, shoulder injections, and trigger point injections on the back and neck. It's amazing how after doing it a few times, I don't think anything now of sticking a 1.5 inch needle into somebody's knee. The first time I was terrified. Sometimes I still need to stick twice, but I've gotten pretty good at finding the spot, even on tough knees. I've also significantly improved my radiograph reading skills. It's basically a necessity as when I present a patient to my attending he pulls up the radiograph and says ok, show me the problem. After a round or two of "uhhhh, I can't see anything" I started staring at them for a while, and started to see problems. Sometimes I still don't quite make out where the fracture is, or what the problem is, as on occasion they appear invisible to my eye, but I feel much more confident.

This has probably been my first no-holes-barred introduction into insanity medicine. We have easily seen 100+ patients some days. There are anywhere between 4 and 6 people handling patients in the clinic, so do the math.

Yesterday was quite hectic and frustrating because for whatever reason (cough cough lazy, overly-socializing receptionists cough cough) patients scheduled for 1pm, who had checked in at 1230, weren't brought back to the clinic until after 1:45. All the while we are literally sitting around twiddling our thumbs wondering where in the world our patients are, and having to accept the reality that we will not be leaving before 6:30. Oh goody. Throw on top of that the usual dose of hospital politics and drama from that person (and every group has one) and it was just a frenetic afternoon. Sometimes you just gotta dance. 

Giggles...

Falafel sandwich - $5


Mocha latte: $1.95

QOTD from your colleague during lunch: "Due to some horrible mistake I was born to cold weather parents who had no money." -- priceless

Part of the job

As part of our surgery rotation we are requiered to attend clinic several times a week with different surgeons. Surgeons, in general, are a rather cantankerous bunch, with a quick temperament and not always the best people skills. I guess this makes sense considering most of the people they deal with are unconscious.

Yesterday I was working with Dr. Snarky Surgeon, and we had a morbidly obese patient referred in due to hernias. I spoke with the patient prior to the doctor, and it was obvious that this patient is very unhappy. Due to the patient's size, comorbidities, and the very low risk of the type of hernias she had, the doctor did not feel she was a good candidate for surgery. At this point the patient became very upset and visibly frustrated due to her situation. Though I agree with the doctor that most of her problems are not directly related to her hernia, but more likely related to her weight, I did not like the manner in which he lost his patience with her. In fact I felt very bad for the patient because I would not want to be spoken to in that manner. As such, I stayed back after the doctor and I tried to speak with her for a few moments. She discussed some of her problems in more detail, and it did indeed seem that she has some degree of depression. I can't say that I wouldn't feel the same way given similar circumstances. I listened to her for a few moments, and tried my best to reassure her that though at the moment surgery was not an option, that her primary could either give her some help with her frustrations and feelings of emptiness, and if he couldn't he could refer her to someone who could.

Patients like that are challening, saddening, and remind me of why I'm here. I hope I never forget that underneath medical problems are real people.

Today's patient encounter...

Patient: "What happened to your hair?"

Me: "It fell out..."

Owned.

Do I Wet Myself...or Laugh?

While in Surgery Clinic today (an ever-fun game of peeing in the wind to see which doctor wants us where and when), I had this patient.

Me: "Good afternoon. I'm here with Dr. Snarky Surgeon. My name is Luckyone. How are you?" *Out goes the hand to shake*

Patient: "I have OCD. I don't shake hands."

Me: Oh goody. This must be good. (I've found the best way to handle patients with psychological problems is just simply acknowledge them, and move on with minimal to no pandering.) "Ok. No problem. What can we do for you today."

Patient: "I'd really rather talk to the doctor alone, is that all right with you."

Me: "Of course, absolutely. Whatever you are comfortable with."

Five minutes later: Surgeon to me: "She told me that since her operation she has needed to wipe more on the left than the right. What am I supposed to do with that?!?!"

Do I wet myself...or laugh??

Oh boy...

Doctor: "So, luckyone, have you ever done sutures?"

Me: Um, once, on a chicken breast many moons ago. "No."

Doctor: "No? Good. You're doing the next ones."


And such was my second day and first scrub in during my surgery rotation.