bellyaching

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

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.

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

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

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

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

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

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

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

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

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

it was all going well until...

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

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

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

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

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

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

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

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

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

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

old and trauma don't mix

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

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

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

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

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

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

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

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

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

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

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

the yeller

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



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



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



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



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



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

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

intro

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

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

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