vip's

There are several things that drive me up a wall in my chosen profession. One of them, if not the worst, is the concept of the "VIP." It's the idea that a patient gets preferntial treatment over other patients because they are a professor, or a dean, or own some influential company.

Everyone should be treated the same way. Period. If you call the families of your patients to update them on a regular basis, good. Do the same for the "VIP." Don't do it more.

Some families need more time spent with them so they understand what exactly is going on. Usually they are either very, very smart or they're... not. If your practice is to routinely spend whatever time a family needs, good. But don't do it just because they're "VIPs."

Everyone gets sick. People get in traumas. People get cancer. Yes, even the people society labels as "important" are susceptible to such things. But that distinction should disappear when they walk through the door. Which, by the way, is where I leave my ego.

it was all going well until...

Today was a very busy day in the OR. Both of my attendings were operating. We asked for help from some other attendings on one of the cases from another attending, but he couldn't come at the last minute because of an emergency. One of the cases was supposed to be a Whipple and the other was a partial/subtotal gastrectomy. Both are fabulous Chief level cases and, as much as I would have liked to do both, I haven't yet developed the ability to be in two places at once (much to the chagrin of my attendings). I've already participated in about 6 Whipples, which is about five more than most Chiefs at other surgical programs get, so I chose the gastrectomy. Besides, there is a much higher chance that I'll do a gastrectomy when I'm done with training than a whipple.

First thing was first; find where the stupid thing is in the stomach. One might think we should have known before we got into the operating room, but because of insurance reasons, the gastroeneterologist and the CT scans were done at outside facilities. Reports from both the EGD and the CT scan were woefully inadequate and didn't give us enough information.

So we did the EGD and found that the lesion was in the worst possible part -- on the lesser curvature about 1cm from the GE (gastroesophageal) junction. The board answer for an adenocarcinoma in the cardia is to do an Ivor-Lewis esophagectomy. But what does one do for a benign lesion? We decided to do a proximal gastrectomy. Risky, I know because of the retained antrum, but this guy really didn't want a total gastrectomy and he's so old I'm not sure that he would have tolerated it very well.

The dissection was difficult because he was so fat, but it went well. We did our resection, anastomosis, vagotomy, pyloroplasty and it all went well. At the appropriate time, we asked the anesthesiology resident to place an NGT tube (N=naso) so we could safely navigate it past our fresh anastomosis.

We finish the case, I carefully apply the dressings and take the dressings down. Just in time to see the anesthesia resident pulling out the OGT (O=oral).

"What the hell are you doing?" I asked.

"Oh you want this to stay? But it's an OGT."

"Yeah. That's why we asked for an NGT."

"F--K," comes flying across the room from my attending. "You've got to be f--king kidding me."

We got the EGD tower and scope back in there. Our anastomosis was intact. We had to blindly place an NGT and check an x-ray in the recovery room. It looked ok. But only time will tell. If he goes into a-fib or becomes febrile tonight, we'll know it really wasn't ok.

old and trauma don't mix

I'm a firm believer that ER's get busier around a full moon. Add this month's full moon to the fact that it's Halloween weekend, and our trauma bays have been hopping.

One of today's victims is a sweet octogenarian who got hit by someone running a red light. (I wonder if he was coming from a Halloween party?) He's got 9 ribs and a scaupla fractured on one side. Alone that may not be such a bad thing, aside from the fact that it hurts. Add to that situation his age, his extensive cardiac history including an aortic valve replacement, requiring full anticoagulation, and it's a different situation entirely. For someone like this, this could be his terminal event. Even though he's a walkie-talkie (admitted walking and talking).

It reminds me of a situation I was in not too long ago. I was covering a patient who was recently extubated and was recovering from multiple rib fractures and ARDS. When he was intubated, he was fully awake and communicative, writing notes on greasboards and such. One of the repeated messages was "Get this tube out!" When we extubated him, we thought he'd fly. But he didn't.

I went up to see him before the accumulation of carbon dioxide in his blood renered him incapable of making decisions for himself. I oriented him to time, place, and situation, just to make sure we were all on the same page. I then told him that the way he was breathing would not be sustainable for much longer and if he wanted to live, he would need to be intubated again. His eyes got wide and he shook his head and hands an emphatic "NO." I told him I thought his condition was reversible with time and the tube wouldn't be permanent. "NO." I also had my head on straight that night and thought it a good idea to ask him about the specifics of his DNR wishes.

So, I called in his family so they could come and be with him in what would likely be his final hours. The daughter was first, and she really didn't know what to say. She deferred to her mother, who was the durable power of attorney.

"You have to intubate him," was the answer I got.

"I know this is a difficult situation for you, but based on what your husband told me, I can't do that. I need to follow his wishes."

"Ok. We're coming. My son lives in the area and he'll be there soon."

They were a 2-3 hour drive away. Soon the patient's son arrived and again insisted that I intubate. I tried to explain to him several times that we had a converation witnessed by at least four members of the staff whereby I could not intubate him. He started to get verbally belligerent, but I stood my ground. I knew what my patient's wishes were. And I was going to follow them.

I did. To the letter. And he died shortly after his wife and daughter arrived.

I really hope this doesn't happen to my new patient.

the yeller

Most surgical residencies are set up where you rotate on one service, say vascular surgery, for a while, and then you switch to something else like cardiothoracic. The purpose of this is to create a well-rounded general surgeon.



I am currently on a rotation that deals with the liver and pancreas. We do some of the biggest surgeries there are, like Whipples. The only thing bigger would be a liver or heart transplant, really. Which means that almost all of our patients are very, very sick, and/or have a very bad cancer. There is a reason there is the old surgical dictum of "Don't f--k with the pancreas," yet we do on a nearly daily basis



The surgeon in charge (we'll call him Dr. P) is a yeller. Maybe becuase of all the stress of these big operations? But even outside the OR (operating room), he yells and treats people like sh-t. You know, condescending, insulting, that sort of thing. They say he's calmed down over the years (after he had a heart attack), but it's hard to imagine how things can be any worse.



A few days ago, I was in the OR with Dr. P a few days ago. It was a routine surgery for him, really, but one that required the organization of a lot of staff to run machines that were out of the sterile field. We were doing an RFA for metastatic renal cell carcinoma, which meant we needed to use the ultrasound probe directly on the liver to find the tumor. Then we needed to use the radiofrequency machine to fry it. Each machine is run by a separate person, and when we needed them, neither of them were in the room.



We paged them. And waited. It was probably only a minute or two, but in the operating room, if you're just waiting for something, it seems like an eternity. Then the screaming began. "Where is Carl? I want him in the room NOW! Get him in here NOOOW!!!! And write his ass up!!!!"



Once that starts, it just perpetuates itself. The yelling continued. At the scrub nurse. At anesthesia. At the circulating nurse. The only person that didn't get yelled at was me. Which is good, but I'm stading there, doing my absolute best to read his mind about what he wants me to do so I don't get yelled at. The silly thing was that the patient was fine and the only reason the tantrum occurred was because an entire slew of people weren't standing behind him ready to jump the second he spoke. Yelling can be a normal thing when someone is dying just because of the stress of the situation. But when you have to wait a few minutes because someone had to go the bathroom or something?

There is just no reason to be that way. None.

intro

Welcome to the world of surgery. Where nothing heals light bright lights and cold steel. I'll hopefully be able to provide an intimate look at the work life of a surgery resident. I've been doing this residency thing for a while -- 4 1/2 years to be exact -- which means I'm in my last year of training. Now I'm looking for a job and all the fun that entails with the way our health care system is.

I realize I'm late to the scene of medical blogging, but that's okay. Many of the other blogs out there belong to the world of emergency medicine, internal medicine, pediatrics. As members of those specialities will immediately tell anyone, there is nothing quite like surgery.

Sleep deprivation, abuse, miracles, tragedies. Comin' right up.