sunday, bloody sunday

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

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?

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!

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

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

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

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

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

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

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?

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

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

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

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

...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