Monday, December 31, 2007

'07 ---> '08

This coming year is going to be one of great change for me. I'll be graduating in just six and a half short months. Finally, after over a decade, I'll be a "grown-up." Qualified to do what I have been called to do. I'll have to go out there and find a job. Fight with insurance companies to get paid for what I do just like every other surgeon in America. I'll have to sit for the Qualifying Exam to be a board certified surgeon. Somehow I'll have to find the confidence that has been eluding me that I am competent.

We in the medical field are used to change. We deal with it daily. We expect it. Why else would we admit someone for "serial abdominal exams"? We are ever prepared for the moment when the generalized abdominal pain turns into peritonitis and we're heading down to the operating room.

People generally don't like change. Change is scary. It requires you to alter your way of thinking. Even when people stay awake past midnight, they don't register the fact that the calendar day is different from the one in which they woke up. It's just easier to pretend it's the same day and things change while we sleep. But many of us find ourselves working past that magical moment that makes one day past and the next one present. We can't pretend; it is imperative that we change our mindset and put in the medical record that it is a new day. Sometimes, when I am exceptionally tired, I'll subconsciously fight that. Even well into the next morning, I'll put the wrong date on notes and have to scratch it out. The new day came; sometimes with me, sometimes without me. But tonight is different. Nearly all the world will be cognizant of that moment. And with that will be celebrations of change... of a new day... of a new year.

So here's to the new year. Learn what you can from last year and then let it go. Get ready for 2008 -- for the planned and the unplanned.


Thursday, December 27, 2007

i may be glowing, but not from radiation

After the events of the last few months, I started asking around about x-rays and radiation and all that. Turns out that the lead we wear blocks almost all of the x-rays. And there is lead covering the source on the C-arm at this hospital, which blocks about 90% of the radiation at the source.

Our x-ray tech said that our attendings, who are usually closer to the source, are well below the recommended dosage on their dosimeter. And that is worn on the *outside* of the lead apron.

So, I have concluded that my eggs are safe. I'd hate to fry them before they had a chance to be put to use!

The glowing must be from my most recent facial. ;-)

Tuesday, December 18, 2007

am i glowing?

I'm still on vascular. Been sprayed a few more times. If it's not blood, it's contrast that we use for the endovascular stuff. Which, by the way, there is a lot of. Five or ten years ago, a chief resident's experience on vascular surgery meant a lot of complicated "re-plumbing" jobs: extra-anatomic bypasses like axillary-axillary-femoral-femoral bypasses, in situ bypasses like femoral-popliteal bypasses or femoral-anterior tibial bypasses, elective open AAA repairs, and access for hemodialysis.

The access hasn't changed much; there are still just as many people getting into renal failure from hypertension or diabetes than there ever were. Maybe even more. But most of those big bypasses have fallen out of favor now that we have endovascular techniques. When I explain it to people, I tell them that we are trying to fix their pipes from the inside instead of laying new pipes. Roto-rootering and stenting whenever possible. No big incisions for these guys to heal, which often never healed anyway and ultimately ended up in amputation.

That means we have to use contrast and x-ray to see our work and to tell us which vessels to fix. Which means that I'm getting exposed to tons of radiation. I didn't realize just how much until last week when we tried to fix a leaking AAA with endovascular techniques. Yes, I know it's an emergency and an argument can be made that we should have just done an open rapair to begin with, but this guy was hemodynamically stable when we started and my attending thought this would be the best thing for him... provided it worked. (It didn't, by the way. He started to crash, we opened, repaired it, and he died in recovery.)

The drive in total for that one case was over 90 minutes of x-ray exposure. That's more than the recommended exposure in one month, someone told me. Not to mention the fact that the hospital does not provide leaded glasses to protect our lenses from developing cataracts, which is a known long-term consequence of x-ray exposure. How is that even allowed?

I have another combined open/endovascular case tomorrow. With an attending who says that for endovascular work, "Time should stand still." Easy for him to say, he's old and he's already had his kids. Not to mention the fact that he's an older attending and is himself still trying to master the various endovascular techniques that are available and does most of the case himself. Not to toot my own horn (and if you knew this attending, you'd know I'm *not*), but *I'm* much faster at endovascular procedures than he is.

Tuesday, December 4, 2007

the worst complication

Several months ago, I was on a rotation that dealt mainly with "foregut" surgery and hepatobiliary cases. On this service, that meant anything from the gastroesophageal junction to just below the ligament of Treitz, including the liver, common bile duct, pancreas, and duodenum. I got to see tons of gastric resections, whipples, ampullary tumors and pancreatic tail/body tumor resections. The operative (no pun intended) word here being *see*. These cases were often so big that the chiefs on the service were relegated to sucker/bovie monkey.

One of the operations we did was a vagotomy and antrectomy for gastric outlet obstruction - a surgery that is nearing it's end in the practicing world of surgery and being seen only in the text books. This is largely in part to the development and use of proton pump inhibitors, which have all but eliminated the worst complications of peptic ulcer disease. Sure, we'll occasionally see a perforation or hemorrhage from a gastric or duodenal ulcer, but gastric outlet obstruction? Most of my attendings haven't seen that in about 10 years and I, in my short amount of time in the OR have *never* seen one.

Our patient was skinny, but by no means cachetic. The EGD that was done said they could not pass the scope through the pylorus, but they could get a wire down... so liquids could pass. His nutrition is probably ok.

My attending and I proceeded with the antrectomy first. That was the easy part. We did a Roux-en-Y anastamosis instead of a Bilroth II. I'm not sure why we chose to do a roux, and I have yet to find a satisfactory answer, either from my attending at the time, any other attending, or the literature. He again reinforced his notion that we residents are relying too much on staplers and had me hand-sew the anstamoses, which was great.

Now for the vagotomy. We felt just above the gastroesophageal junction for the NG tube, which we had the anesthesia resident pull up for our anastamosis. He wasn't happy with how flimsy it felt in the esophagus, and asked him to replace it with a small bougie for easier palpation. The posterior vagus was the first and easiest to find. It was very large; almost as big as the sciatic nerve, and we were able to do the "plucking of the violin string" that I've read so much about. We sent a piece of it off to pathology to confirm nerve tissue because that's what the books tell us to do, but we were sure we had it.

The anterior vagus was quite a different story. My attending was dissecting through connective tissue, closer and closer to the esophagus. He would use the Angle of Truth (aka, right angle instrument) to lift up a few strands so I could use the electrocautery. I was getting uncomfortable at how close we were to the esophagus and I kept hearing other attendings in my head... "The esophagus has no serosa, so when there is a hole in it, it is very difficult to repair." More dissection... sh*t. There's the bougie. Ok, we'll fix that later. That happened about two more times with even more obscenities.

Then he called another senior surgeon who has experience with this operation into the room to help. (Which, by the way, gave me an immediate promotion to scrub tech assistant.) They got into the esophagus two more times. They found what they thought was a piece of nerve and then started to repair the esophagus as best they could by primary closure. We finished the case and took the patient to the ICU.

Five days later, we got an upper GI series, where the patient swallows water soluble contrast and we check for leaks or obstruction as seen on x-ray. No obstruction anymore, and reportedly no leaks per the attending radiologist. I checked the films myself, but saw an area that looked like a leak to me. I paged him anyway, unaware of the fact that my attending was about to do the same thing. He assured us both independently... no leak.

We gave him clears and that night he went into renal failure and respiratory distress. We got a CT scan and a *different* radiologist read the CT scan. He compared to the UGI we got two days prior.

"Who told you guys there was no leak?"

"The attending."

"Well... he was wrong. There's a BIG leak."

Oh. Crap. Back to the OR to suck out the cranberry juice and jello that was now free floating in his peritoneal cavity. We got an endoscope and checked the esophagus while other members of the team had the belly open. The esophagus was attached to the stomach by two tiny bridges of frail tissue... the rest had simply disintegrated, likely as a result of the holes that were made in the first place, his unrecognized malnutrition, and having food leak out through it and cause massive inflammation. The only saving grace here was that the damage was in the abdomen and the mediastinum was free from the bomb that was happening a few centimeters below. If he had mediastinitis on top of everything else, he would have likely died before we got to the operating room. Maybe it would have been better if he did...

We completely disrupted the esophago-gastric connection, with the inention to go back in 6-9 months to reconnect him. He spent months in the ICU and had multiple CT-guided drainage procedures. Fevers, bacteremia, fungemia, delerium, and pneumonia visited him during his course.

Then I rotated off service. I would occasionally see the chief who replaced me at conferences and I would ask how he was doing. "Oh, you know. Hanging in there," was usually the answer. Until last week, when I was told he was going to die.

And he did.

I'm not sure if I have a point, really. I'm just retelling a story that I was a part of. I feel horrible. He came to us a "walkie-talkie" as I like to call them, and we discharged him to God. And what about his family? They were constantly overwhelmed by the whole thing. His surgery went from, "Oh, yeah, we can fix that. He'll stay in the hospital for about a week, and then he'll be able to eat" to "I'm sorry, but your dad is very sick and may not live through the night."

There is obviously nothing we can do now for this patient. But it is my responsibility, nay, my moral obligation to learn what could have been done differently. I have a few things: 1) always check an albumin and maybe even prealbumin before a major, but elective case. If it is inadequate, arrange for supplemental nutrition. 2) If I ever get into the esophagus at the GE junction, I will protect my repair with a Nissen fundoplication (wrapping extra stomach around the repair for reinforcement). 3) If I'm in over my head in the OR, at any point in my career, call for help. It didn't really work this time, but at least he had someone else experienced in the room.