Bright Lights, Cold Steel

sunday, bloody sunday

2008-01-22T11:04:00.000-08:00

I was supposed to have the whole weekend off. Quite a rarity for a surgical resident, acutally. So imagine the dread that I woke up with when my pager went off on Sunday at 0115. The resident responsible for the page regretted to tell me that the vascular attending had accepted the transfer of a patient with a ruptured AAA and that the other on-call people were far to busy with traumas to scrub the case. I'd have to come in and the patient was on his way.

Maybe it was being just woken up with really bad news. Maybe it was knowing that I was going to spend Sunday studying for my in-service training exam that is coming up with week, and now I probably won't. Maybe it was knowing the futility of the proposed surgery and there is a 50% mortality associated with it and there is likely an even higher mortality with the on-call attending. Maybe because I was going to have to scrub with the attending who bathed me in blood a few months ago. But for whatever reason, in a very uncharacteristically surgeon move, I started to cry.

I pulled myself together, got my contacts in, and drove to the hospital. When I arrived, they were checking him at the front desk of the OR. He was begging for another pillow.

We opened the abdomen and didn't find an intraperitoneal rupture; rather there was a quite extenisve retroperitoneal hematoma. In addition to the infrarenal AAA, he had aneurysmal extension into the right common iliac and a separate common femoral aneurysm. Just to add something interesting to the mix, his INR was 3 (normal is 1) because he was on coumadin for his chronic atrial fibrillation.

Just when we were gaining control of the neck of the aneurysm, my attending and I had a very interesting exchange:

"You know, I should have probably never accepted this transfer."

"Why, because of his INR?"

"Yeah. That and the fact that he was turned down by seventeen other surgeons before they called me." Seventeen may have been a bit of an hyperbole, but you get the point. I certainly did.

"Well, then why did you accept him?" A little insolent for me, but it was 3:30am, after all.

...

"Just before I received the call about this patient, I had won a $600 hand of poker." The only way I took that unfinished thought was that he'd just had a bit of luck and thought it would continue.

I'm sure you can predict how things went from here. We had some hairy moments of hemodynamic instability in the operating room. 16L of blood loss; 4.2 of which we returned. Dozens of blood and blood products. A tube graft was sewn in; we never even laid eyes on the right iliac. Due to the massive and ongoing fluid resuscitation, his bowel was too edematous to close the abdomen, so we had to place an abdominal wound vac on.

I told my attending we weren't dry when we placed the wound vac. (Meaning that there was something still actively bleeding.) He insisted that he was diffusely oozing from all exposed surfaces from his hypothermia and coagulopathy.

In the recovery room, the wound vac put out another 6L. The family didn't want us to go back to the operating room to find the source of the bleeding. We stopped transfusing and he died there.

I am not cut out for vascular surgery. I admit it.

a new cardio work out

2008-01-17T11:15:00.000-08:00

I couldn't make it to the gym yesterday. It always seems that the days we need those endorphins the most are the days we can't get there.

Would killing my intern be considered a cardiovascular workout? I guess it would depend on the method. Shooting? No. Stabbing? Maybe. Multiple stabbings? Possibly. Strangle with bare hands followed by kicking/jumping? Definitely!

Oh, and I'm not just being an evil chief here. He completely deserves it. He's like a negative resident. It would be easier if he weren't even here and we had to split his work up among the rest of the team. He coutns as negative because he has to be checked up on, which takes longer than actually just doing it yourself. :-P

how much do i need to take?

2008-01-17T10:58:00.000-08:00

Accesses for hemodialysis fail; every single one. They all eventually need to be revised or abandonded in favor of creating a new one. The issue then becomes how do dialyze them in the mean time.

A patient currently on my service is having access issues. We tried to de-clot his graft with this slick endovascular device that is like a squishable egg beater. When we were done, we didn't think it was going to work and that he'd need to be revised in the operating room the following day. But he still needed to get dialysis. So I had to place a quinton (a non-tunneled central venous catheter).

Before having to place the quinton, I was his room with my attending so we could let him know what the plan was. From the start he was belligerent and not listening. He was yelling at his wife. Then my attending told him to not yell at his wife like that. He proclaimed that we weren't helping him and he was going to leave. He stated that we never explained anything to him and he had no idea what was going on. He just kept going on and on...

I'm sure having renal failure and getting dialysis is a very frustrating life. I can't even imagine how much so.

A few hours later, I was back at his bedside, ready to place the quinton. He kept touching the sterile field and his groin so we had to keep re-prepping. I kept trying to explain what I was doing, since he was awake and all. But every time I opened my mouth, he would just start yelling, stating that he doesn't understand what we're doing. Keep in mind, it's been explained about 10 times at this point.

"Sir. Do you want me to explain what I am doing right now, or not?"

"I don't know what's going on or WHAT you guys are doing."

"Ok. I'm going to take that as a no."

I placed the quinton without any problems. Accessed the vein with one stick, so he couldn't even complain about that. I warned him when I had to stitch it in. And, yes, I used lidocaine. I told him when I was done and he literally sat up and started yelling "PRAISE GOD!" and waving his hands around my face.

"Here! Let me praise you some more! You need lots of praise, don't you?"

"No, sir, I don't need any praise. I'm just trying to take care of you. I don't need any thanks for it."

"You're not trying to take care of me. I don't know *what* the hell you're doing. And you can leave now."

"Ok. Well, please try to remember to not eat or drink anything after midnight so you can have your surgery tomorrow. The dialysis nurse will be here soon. Can I get you anything?"

...

"Can I have some ginger ale? please."

So I bring him his ginger ale.

I can usually take patient abuse pretty well. I know they're sick and I'm a safe target and all that. But he got under my skin. Don't know why. Should I have set better boundaries? Told him to be quiet? I know I could have handled things better.

hi everybody!

2008-01-13T20:06:00.000-08:00

I'm on trauma call today; I'm about 14 hours in and I've had six already. All moderate blunt traumas. (Meaning not really sick, but needs the activation of the trauma team. Trauma team = surgery trauma service, senior ER resident, x-ray techs. Blunt injury is like a motor vehicle or motorcycle collision. Penetrating is like a stab wound or gunshot wound.)

EMS brings the patient into the trauma bay and they've got en route vitals and the story of what happened, as well as the condition at the scene. When they arrive, there are at least 10 people in the room and it can get pretty noisy. But we all need to shut-up and listen to the whole story, which can be difficult at times. Sometimes the medic is in training or the firefighter isn't used to giving an oral narrative of what happened and sort of stand there waiting for an invitation to speak. So I say something to let them know we're ready for them.

Tonight when they arrived, I exclaimed, "Hi, everybody!"

The ER attending was standing right next to me and immediately answered, "Hi, Dr. Nick!"

done deal

2008-01-13T07:20:00.000-08:00

Two posts back, I wrote about a gentleman who needs an amputation. After many more meetings and disscussions about the necessity of it all, he and his daughter agreed. We did something pretty clever about the wound on the other leg, though. It needed a skin graft in order to heal.

Skin grafting is very cool. If you envision the skin as having say... seven layers or so, we take off the top 3-4, depending on how thick we want it to be. Then we take this motorized tool that resembles a cheese slicer and shave off the top part of the skin. Then we usually end up meshing it, so it can expand to fill the wound without taking too much skin from the donor site. The little holes that make up the mesh get filled in by new skin cells, but the healed result will always have a faint mesh pattern. So now the patient has to heal the harvest site in addition to the original wound. The pain is often worst at the harvest site; imagine a *huge* rug burn.

Here's where our neat thing comes in. We did the amputation, but didn't pass the leg off of the field right away. Then I prepped the wound to receive the skin graft while my attending grabbed the leg and harvested the skin from *that*. No donor site to heal!

grandpa

2008-01-07T13:40:00.000-08:00

Every academic program has at least one. An old surgeon, usually a former Chair of the department, who at one time was a legend. Perhaps even one of the greats of surgery. And if they weren't great, they knew the greats.

We have one of those. He goes to every M&M conference and adds his two cents to an interesting discussion, usually with data and practice patterns that were cutting edge thirty years ago. We all listen politely, giving him the respect and deferrence someone of his years and experience deserve.

When I was an intern, he still operated. At the time, he would only operate with the chief resident because, more often than not, he was not capable of doing the operation himself due to his tremor. But he had enough experience that he would be able to walk a chief through it. He doesn't operate anymore.

There is a clinic that he staffs for the residents once a week. (Don't ask me what he does the rest of the week, but he still comes to work.) I wish we could just divide up those patients amongst the rest of the attendings in the division. I'm sure his bedside manner was acceptable when he was younger, but you just can't talk that way anymore. Allow me to provide some examples:

Number 1: "You're much too fat. Just look at these rolls. [Grabs rolls of fat on the abdomen and shakes them.]" Then he turns aside to whatever resident or medical student is in the room and says, "We could put her in a cage for two weeks, not feed her, and she'd be fine."

Number 2: "You're too fat. What do you eat? Tacos and beans all day?"
"I'm not Mexican. I'm Bolivian."
"What do you eat then?"

I could go on, but the other examples are just as bad and all in a similar vein. As much as we respect him for the phsycian and surgeon he was, someone needs to sit down, talk to grandpa, and take away his keys. He can't drive anymore.

what do you say? part II

2008-01-04T19:07:00.000-08:00

Another patient on my service is also in that proverbial place between the rock and the hard place. He's young as far as our patients go -- only 51. But he has the body and face of a septuagenarian. Through a constellation of events, some self-induced, some self-neglect, some medical neglect, he is facing an above knee amputation.

He was trasnferred to our facility for a "higher level of care," which sounds like the transferring facility has reached the limits of what they can do, either with expertise or equipment. More often than not, however, this term just means that they don't want to be bothered with the difficult work up, or they have done a "wallet biopsy," determined that the patient doesn't have insurance and don't want to do something for which they will not be compesated. But I digress.

We accepted this transfer because he had a huge saddle embolus from new-onset atrial fibrillation. The thrombus was occluding his common iliac arteries that eventually give blood supply to the legs, which meant that he was not receiving much blood supply to his legs. Superimpose this condition on pre-existing peripheral vascular disease caused by years of smoking and hypertension, and he has experienced necrosis of most of the toes on one of his feet. And this was all before we got him.

When he arrived, we were able to remove the clot from his arteries and restore the inflow, but much of the damage had already been done. In addition to the necrotic toes, he has a wound on his heel that extends to the bone and Achilles tendon as well as a large wound with exposed tendons on the lateral aspect of his leg. We could try to re-vascularize his leg and try to restore some blood supply to try to heal his leg wound, but he has a large vegetation on his mitral valve causing a large degree of mitral regurgitation and congestive heart failure. Simply put, he simply would not survive the major surgery needed to restore blood flow to his feet.

And this is how I received him when I arrived on the service. He was slowly getting his mind around the fact that he was going to lose his toes. Everyone but the patient and his family knew that the heel wound would not close and he would lose that, too. But so far, everyone was dancing around the idea of a bigger amputation and not talking to him or his family about it. That's easier, isn't it? I took down the dressings on the leg in question and knew immediately that a standard below knee amputation would not even be enough. The leg wound is on the posterior flap that we would create to close the stump with. He needs an above knee.

I tried as best I could to bring up the idea to him gently. I used words like "you should start thinking about the possiblity that we are going to need to amputate your leg" and other things to that effect, but no matter what or how I said it, he bawled and his daughter was hostile. Not that I'm offended in any way, but we don't have a magic scalpel.

Exactly how do you tell a relatively young man that one of his legs needs to be removed? And that after he recovers from that, he'll need open heart surgery? And after that, he may need major revascularization procedures?

what do you say? part I

2008-01-03T18:32:00.000-08:00

Medical school can teach you a lot of things. Most of what they teach, they do very well: pharmacology, anatomy, physiology, pathology... One thing they don't spend much time on is how to deliver bad news. If they do have a one hour lecture devoted to it, consider yourself lucky. But something like that can't be taught in one hour. For some, even a lifetime isn't enough.

Learning how to deliver bad news seems to be part of the job description of a physician. We can't cure everything that crosses our paths. People don't get better, become debilitated, die. We should be able to do this very well.

For us, the new year has brought us to new rotations. I'm still on vascular surgery, but I'm at a different hospital. I've inherited some very sick patients who have run out of options.

One woman is in her 80's. She is on dialysis, which requries the ability to remove blood at a high rate, run it through a filtration machine, and return it to the body at the same rate. This is usually performed through what is called "access." Access can take the form of a fistula or graft in the arm, which is where we surgically make a connection between a large artery and a large vein in the arm. Or it can be via a large bore catheter with two ports sitting in one of the large veins in the neck.

Eventually, fistulas will become clotted and stop working. We can try to save the one they have through various means, but sometimes they need a new one. So you march up the arm towards the axilla making more connections between artery and vein in an attempt to keep them on dialysis.

Once all those spots on both arms are used up, you can try to do something in the groin. But these can become infected and don't usually last that long. Then all you're left with is the catheter version of access, which carries with it risk of infection or clotting of the vein in which it sits.

What happens when you run out of places for the catheter and something else hasn't killed you first? You die of renal failure. It's not a horrible death, really. The toxins in your blood make you sleepy so you just get to the point that you go to sleep and don't wake up.

Back to my patient. She's in her 80s and she's used up all the spots on her arms. All of her large veins are clotted. She is currently receiving dialysis through a catheter that is placed through a lumbar vein that goes directly into the inferior vena cava. That's the last spot. And even that is more than most people get.

Let's complicate things a bit more. We've been keeping her anticoagulated (blood thinned) on coumadin to help prolong the day when she will clot off that catheter. But for some reason (that happend before I got on the service) the blood was thinned too much (INR = 12) and she had an upper GI bleed. We the surgeons and the medicine doctors have weighed the risks; continuing anticoagulation to prolong the inevitable is not worth risking another potentially fatal GI bleed. Which would mean that we need to talk about the time when the catheter clots and we need to set up hospice care for her.

Add this to some very dysfunctional family dynamics involving debates over religion and a language barrier, and I'm a loss. Today we had a family meeting with a skilled palliative care specialist who is helping us from a hospitalist standpoint. He was able to cut through the communication issues with the family and get them to agree that the patient will indeed make her own decision about stopping anticoagulation or not. They will only become involved when she is unable to make decisions for herself. That conclusion alone is a huge help; before this meeting the daughter told me that she was "not authorizing" me talking to her mother via an interpreter about these issues.

Now that I have permission, I just have to do it. I've had these discussions before. I'm sure I could do them better. I hope I can show compassion but give her the facts she needs all at the same time.

Part 2 will include another difficult conversation I had today...

'07 ---> '08

2007-12-31T15:12:00.000-08:00

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.

Cheers

i may be glowing, but not from radiation

2007-12-27T09:56:00.000-08:00

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. ;-)

am i glowing?

2007-12-18T17:31:00.000-08:00

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.

the worst complication

2007-12-04T15:56:00.000-08:00

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.

recurring dream

2007-11-28T10:36:00.000-08:00

I almost never dream. Well, that's not entirely accurate. I'm sure I do, I'm just too asleep to remember any of them. Unless they're bad. And I don't have a lot of nightmares either.

But recently, I've had several nightmares about work. Which doesn't make any sense, because I'm not stressed at all. I mean, last week, my service was down to zero patients. ZERO. So why I'd be having nightmares now about work is baffling.

The first one I remember vividly -- also uncharacteristic. I was in the OR at our main hospital and we were doing some routine general surgery case laparoscopically. Except they wanted me to use the da Vinci robot, which I have only seen being used from across the room. I sat down at the unit and tried to manipulate the instruments that were in the patinet's insufflated abdomen, but it wouldn't work. They wouldn't move. The attendings in the room were lauging at me and then they got frustrated that I couldn't do the operation and took over, all the while making comments about how incompetent I was. Then I woke up.

I then had the same dream twice. I don't remember what happened, but I know it was something similar that happened because I felt the same way. I hope this all gets worked out soon, whatever it is. This fluffy psychiatry stuff is all very frustrating...

i must have a target on my head

2007-11-28T10:12:00.000-08:00

Now that I'm on the vascular service, we're doing lots of endovascular procedures, which is where we gain access to the arterial system at a location remote from the site of disease and use various wires, stents, and balloons to treat arterial (or sometimes venous) disease elsewhere. At the end of the case, there is a hole of varying sizes in the artery where our access was. There are all kinds of devices that have been developed to close this hole with a stitch or clip or whatever. Like all devices, sometimes they fail. When that occurs, we resort to the old fashioned way... hold pressure for a very long time.

A known complication of endovascular procedures is formation of a pseudoaneurysm which is when there is a leak in the artery and an inflammatory capsule forms around the flowing blood. The risk of this happening is increased if the patient requires systemic anticoagulation (for a heart valve, for example) or if there is a hematoma.

We were recently doing a groin exploration for just such a complication. We were carefully dissecting around the pseudoaneurysm, keeping in mind that the only thing separating us from a blood volcano was a thin wall of inflammatory tissue. Our dissection was almost complete... POP!

Right. You guessed it. All over me. It's was quite funny, actually. Not as bad as the last time, but messy enough to require me to wash my face and neck and change my shirt. My attending generously held pressure over the common femoral while I cleaned up so I wouldn't miss anything. With the exception of the anesthesiologist and my attending, the rest of the operating room staff was the same as the first blood bath. After that first one, which is already legendary around here, I vowed that I would handle the situation differently. And I did.

The rest of the case was uneventful. Cleaned out the capsule, gained control of the artery with a fogerty, repaired the hole with a few 5-0 prolenes in a figure-of-eight fashion, closed. The patient is great and going home today.

These two instances by two different attendings leaves me wondering, is this just how vascular is? If not, I may set a record for being sprayed with blood in the residency. I have three more months, so I'm sure I'll find out.

grateful

2007-11-22T10:42:00.001-08:00

...for what I learn from my patients, my attendings, and my students.

...for being present in people's lives when they are the most vulerable and being in a position to offer comfort.

...for whatever abilities I have to do my job.

...to belong to a profession that prides itself in the care of others.

...to be able to experience life-long learning in an ever changing world.

...for the health of my friends and family.

Happy Thanksgiving

bellyaching

2007-11-15T16:27:00.000-08:00

Last week I was bellyaching, as only a resident could, about having to work the day after Thanksgiving in the venous ulcer clinic. We also like to call this the smelly foot clinic. Smelly feet as only diabetic vasculopaths can have smelly feet.

My attending was in a particularly good mood this week, especially after he took the team out for all you can eat Indian food. While he was full and happy, I gingerly broached the subject of moving the clinic to the following Monday. He didn't agree right away, but he didn't flat out deny it either. I let it rest, and when I got back to the hospital, I called the clinic gods and asked what we needed to do to move the smelly feet clinic from the day after Thanksgiving to the next Monday. They said that the attending would have to cancel it, but they needed to know right away.

I paged him immediately and asked him if he was willing to do so. He quickly agreed, and it was done! So instead of examining ulcers and lymphedema, I'll be out shopping, getting great deals for Christmas.

Sometimes it's good to be chief.

no, doc. here's what happened

2007-11-13T14:19:00.000-08:00

It all started out simply enough. Middle aged guy with some right lower quadrant abdominal pain and acute appendicitis on CT scan. It was going on for a little longer than one would expect for appendicitis -- 3-5 days -- but CT scans don't lie with appendicitis, right? He had a white count, but no fever. This semi-confusing picture wasn't enough to convince my attending to come in and take this guy's appendix out in the middle of the night. Admit for observation and serial exams were my instructions.

The next morning, the white count had improved thanks to a little Vitamin Z (zosyn) but he had point tenderness with rebound in the right lower quadrant. Surgical abdomen = surgery. I'm a big fan of the laparoscopic approach in men or women just because of the better field of vision, so we started there.

Once we had the camera intraperionteally, it seemed like his *entire* omentum was simply plastered to the cecum. No 15 minute appy for me. Oh well. So I gingerly start trying to peel away all this fat from the inflamed area. I'm working slowly, because the last thing I want is a hole in the bowel or some bleeding. A few minutes later, I see what looks like a piece of hay sticking right out of the colon.

"Sh*t. Is that really what I think it is? I'm not sure. Best not to say anything yet."

I keep working, and the piece of hay gets bigger and bigger. Except it's not a piece of hay. It's a freaking toothpick.

"Uh, Dr. Jones, I think there is a toothpick sticking out of the cecum. We should open."

"Let's pull it out first!"

I was screaming "NO!" in my head, while simultaneously having visions of feces come flooding out of the hole where the toothpick once was. But instead, I managed to suggest that we open first and then remove the foreign body under more controlled circumstances.

I won, thank goodness. So we made an extended Rocky-Davis incision and pulled up the cecum. The appendix was normal, of course. But about 3cm distal to the ileocecal valve was a *whole* toothpick. We removed it and inspected the damage. The cecostomy was only about 3mm wide, so we closed it with a few stitches, tacked a piece of epiploic fat over it and called it a day.

When I checked on the patient later, I asked him how it came to pass that he had swallowed a whole toothpick and when he thought it might have happened.

"No, Doc. Here's what happened," was how he began his story. Three weeks before the surgery, he was with his buddy and they were doing some fishing. They had reeled in some catfish earlier and his friend had cooked some and made little sandwiches out of it. He was ravenous and started wolfing down the sandwiches, probably not chewing much since he only had like 5 teeth to call his own. In the middle of his sandwich, his buddy informs him that there were toothpicks in the sandwich to hold it all together. Let me tell you, he was mighty pissed at his friend at that point.

After his story, I tried to find some other case reports involving ingestion of toothpicks and GI perforation. They usually perforate in the pylorus or duodenum. The amazing thing about this case was that it not only got past that area, but it made it through all 30 feet of small intestine, *through the ileocecal valve* and perforated in the cecum, which is the largest diameter structure in the alimentary tract aside from the stomach.

blood. bath.

2007-11-09T18:49:00.000-08:00

The other day we were scheduled to do a carotid endarterectomy, which is essentially where we remove the plaque caused by decades of eating Big Macs from the carotid artery. To review a little anatomy, there are two of them; one on each side. Cances are if you've got a messed up carotid on one side, the other side is also abnormal. Sometimes the lesion on the opposite side is not hemodynamically significant, meaning that that single vessel is sufficient to supply blood to the whole brain by itself. But if the plaque is causing stenosis over a certain percentage, the chance of stroke is much higher, or you've already had a stroke. So to prevent a stroke, we scrape out the junk.

During such a surgery, in order to preserve blood flow to the brain, you have to put in a temporary shunt. That's a fancy name for a piece of plastic tubing that diverts blood around where you need to work but gets plugged into the pipeline on the other side. Since these things are temporary, and too much clamping on an artery can cause damage in and of itself, sometimes they fall out. Which is usually ok, because the surgeon is an experienced, skilled vascular surgeon and he can handle the situation. But as this surgeon reminded the anesthesia resident, during this very case, "They don't call me Bloody Smith for nothing."

There we are, with our little plaque spatula (yes, it looks like a mini spatula with rounded edges), scraping away long-forgotten Big Macs, when our surgical field slowly fills with blood.

"Hmm... where do you think that is coming from."

"I'm not sure, you might want to check the shunt," I suggest diplomatically.

"Ok. Let me see about this clamp first."

Have you ever seen those cartoons where a firehose is attached to a firehydrant, the water gets turned on full blast, and the hose flies all over the place? That's precisely what happened, except it wasn't water coming out of the little tube. It was blood. Full blast.

Onto my neck. And my shirt.

I can feel the warmth running under my shirt.

Onto my bra.

Then dripping on my stomach.

I don't remember doing this, but people who were there said I took a step back, looked down at my gown in disbelief. I informed the surgeon that I had to leave. I had to go home and take a shower.

"But I need some help."

"I'll get you some help. But there is blood on my bra, and I've got to go home to shower and change. I'm sorry Dr. Smith, but I cannot spend the rest of the day in bloody underwear and I'm not about to go without, either."

"Do whatever you need to do, but I bring a gym bag and a change of clothes to work."

I left the OR, not knowing how to address the fact that he basically suggested that I bring all my toiletries, make-up, and spare underwear to work everyday in case he douses with me with blood. I walked through the hallways, in my blood splattered boots, looking for my junior resident to scrub in an help finish the case. People got out of my way as I passed them and uttered things like "Oh my God" and "Look at her shirt."

It wasn't a long walk, but it was long enough for me to recall all the stories I had heard from other residents about Bloody Smith in which they or their chief got some inexplicably large volume of patient's blood on them. When I arrived at our workroom, I asked my junior to scrub. I can't remember exactly what I said, all I know is that my voice was trembling with fury. And I said please. We walked back up to the OR, where everything was going fine again. I took off my boots, washed my hands and arms, and told them I'd be back.

I didn't even want to stop and look in a mirror. I just wanted to go home. I grabbed my keys and headed out to the elevators. I saw a nurse from the surgical floor. He looked at my shirt.

"How ya doin'?"

"Awesome."

"I can see that."

I got off the elevator when another elevator arrived to the first floor at the same time. A woman looked at me and asked if I was ok. I said it wasn't mine.

Then I sat in traffic for 30 mintues because the city officials thought it would be good to take a three lane road down to one. The very road that leads to the freeway that would get me home.

I surveyed the damage when I got home. Blood all over my shirt. My bra. A little on my stomach. And my neck. At the level of my carotid. It's a good thing I didn't get pulled over for speeding on the way home; they might have dragged me in as a suspect for murder or something the way I looked. And I'm positive there was a murderous expression in my eyes.

It's not that I have never had blood on me or my clothes. There have been plenty of traumas where I didn't even have time to put a gown on and had to crack someone's chest with cheap-o unsterile gloves. This was different. One because it was on my BRA. That really grossed me out. And two, because this kind of stuff only happens with this one attending. And it's usually completely unnecessary.

P.S. The patient is fine. He got two units of blood in the operating room and was discharged today. He just had to stay to watch the end of Oprah.

day after thanksgiving

2007-11-08T20:51:00.000-08:00

I just found out that we have clinic the day after Thanksgiving. Whaaa??? Isn't that a holiday or something? Not that I expected to get it entirely off scott free, becuase that doesn't happen in residency. But I thought that I'd have to go in, round on my peeps, and head to my nearest mall to get great holiday deals.

But alas, I wiil be in clinic until at least noon, after which my attending will most assuredly want to round, since the OR will be closed except for emergencies. So I'm looking at the mid afternoon before I'm free. On what should be a holiday.

Excuse my particularly whiney mood at the moment. I'll be back to being a kick-ass surgical resident in a bit.

better to be lucky than good

2007-11-07T08:38:00.000-08:00

We were going to do a CEA carotid endarterectomy the other day. This guy's whole story started when he told his PCP about some foot numbness and tingling. For some reason, the PCP thought a total body CT scan would help. It didn't deliniate the source of the numbness, but it did find a mass in the right kidney.

A urology consultation was promplty obtained. When the urologist heard about his neurologic symptoms, which now included intermittent bilateral lower extremity paralysis and aphasia upon wakening, he very appropriately ordered an ultrasound study of the carotids, thinking that he was having transient ischemic attacks. This demonstrated bilateral carotid disease with the right side having greater than 75% stenosis. With or without symptoms, a 75% stenotic lesion is enough to prompt an endarterectomy.

The only problem was that his symptoms really didn't match what was going on. To have one stenotic area cause symptoms in both extremities doesn't make sense. And to have a aphasia, usually the lesion has to be on the left side, not the right.

Fortunatley, the attending who originally decided this guy needed a CEA couldn't do the case and he found a different surgeon. I'm so glad, because I kept telling the other attending, "I'm not sure we can attribute his neurologic defecits to his carotid disease." Which for a resident speaking to an attending is actually saying, "Hey! Red flag here! I don't think we should do this! We need further work up!" All of my protestations were very quickly dismissed.

This new surgeon (who is infintely better than the orignal attending) recognized the problem right away. He pulled me aside in the preop area and told me what I already knew: his symptoms didn't match his carotid disease. He wanted to postpone the surgery and get an MRI because he has a known renal mass, which is presumably malignant and he was worried about metastatic disease in the brain causing these problems.

So we got a stat MRI. It didn't show mets. It showed an acute on chronic subdural hematoma. Turns out the patient was riding his bike a few months ago and he fell. Shortly after that all his neurologic symptoms began.

If we had actually gone through with the CEA, he would have received heparin during the surgery as anticoagulation. It's routine. But for him, it would have caused him to bleed more in his brain. He could have herniated right there on the table and died.

When the second, better attending was told about all this, he simply said, "Well, I guess it's better to be lucky than to be good." But his skills as a clinician were evident. No luck there. Perhaps he meant the patient.

girls in surgery

2007-11-05T17:20:00.000-08:00

There aren't many of us, at least in my program. I'm not sure how other programs are. And it's not because there is any active prejudice against girls per se. After discussing the issue with scores of medical students over the last four years, it really boils down to what people perceive about surgery; both in training and when you're all grown up.

I think those perceptions may have been well earned in earlier years. But now, the way the business of medicine has changed, I think a busy lifestyle is true for surgery as well as pediatrics or internal medicine, which are the other "acceptable" fields for females in medicine. For example, I know an internist who is a partner in a medical practice. She took some maternity leave and then on her months off, had to actually *pay* the business for overhead and such. When she finally did go back to work, she was extraordinarily busy, but she realized that her children needed her; she decided to take some a sabbatical to figure out how she was going to balance her home and work lives.

In my program there are a total of six female residents. We would have had more, but several left for personal reasons or from social pressures in their own lives. Not from any pressure from within the residency. As the most senior female, I have decided to institute a monthly Girls in Surgery dinner. A chance for us to relax and talk about work... or not. First dinner is tonight!

the team

2007-11-02T21:27:00.000-07:00

I cannot underestimate the importance of your team in the workplace we call the hospital. It can make or break you. Or your patients. I'm positive that is true for other areas of business, so forgive me for stating the obvious.

But I had to anyway. To pay homage to my new team, which was created on November 1st when we changed rotations. Everyone pulls their own weight. We all do what we are supposed to do. Even working in the clinic is not painful. The front and back office staff are fun, the love the patients every but as much as we do, and they are competent. (For any non-surgeons out there, clinic is one of the worst places to put a surgeon. Sure, it's where we meet patients we can eventually operate on, but really all we want to be doing is actively fixing something.)

So here's to my new team. Cheers.

vip's

2007-10-31T13:54:00.000-07:00

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...

2007-10-30T17:17:00.000-07:00

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

2007-10-29T03:15:00.000-07:00

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

2007-10-28T08:21:00.000-07:00

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

2007-10-28T06:33:00.000-07:00

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.