Medical student with a past life history significant for journalism, art, and piano, s/p* starting her surgery rotation 1 week ago, presents with aching feet and legs. The symptoms are most consistent with walking all over the hospital and standing for hours in the OR with inadequate footwear. The student does note that these symptoms have not affected her enthusiasm for the surgery rotation, and that assisting in several surgeries last week has only enhanced her desire to improve her surgical skills. Recommend the student continue to read more about the field of surgery, practice suturing and knot-tying at home, and buy shoes that are more comfortable to stand in for extended periods.
Part of writing up a patient note is including your “Assessment and Plan.” It’s just what it sounds like — a very brief synopsis of the person’s presenting symptoms, what you think the cause is (and why), and what you plan to do about it. The paragraph above is my own Assessment and Plan after 1 week of my surgery clerkship. In other words, the main issue is that my tennis shoes simply aren’t cutting it. Aside from that (and being tired from waking up at 4 a.m. — which is just a given), I’m really enjoying the rotation so far.
Of course, I did learn some lessons from my ob/gyn clerkship that have helped. Those of you who follow my story may remember my near-fainting incident during a C-section earlier this spring (see “Getting back up” from The American, the online magazine I write for every month). After that experience, which I attributed to hunger and dehydration, I now keep quick snacks, as well as an adorable 6-oz. water bottle, in my white coat pockets. They come in handy.
On Friday, for example, we had a lot of cases booked, and in two different rooms — eliminating the room cleaning break in between surgeries that gives you time to get something to eat or drink, and use the bathroom. It was around 4 p.m., and I hadn’t had time for lunch. I was staying late that evening too, and didn’t anticipate time to eat dinner either. At the completion of one case, as everyone readied to go to the next, I approached one of the residents.
“Do I have for a 2-minute snack?” I asked.
She looked intently at me as she quickly thought about my question, knowing we were on a tight schedule.
“Two minutes,” she replied.
Thank heavens for that packet of string cheese in my white coat pocket, which was hanging in the hallway just outside the suite of operating rooms. I ate it in three quick bites, and was indeed back in about two minutes.
The clerkship orientation I mentioned in my last blog post has also come in handy. During a laparoscopic cholecystectomy (gall bladder removal), I got to “drive” the camera for part of the procedure. I also did my best to suture closed one of the port sites used to insert the instruments. Getting that needle just where you want it is harder than it looks though, so the resident had to rescue my effort. But I’m resolved to improve.
Those were things I’d practiced (a little), and expected to try. I didn’t expect to get to help with an ulcer debridement. Debridement is the process of removing dead or damaged tissue from a wound, and in this case it was done to try to help the wound heal. After watching the resident and intern, I was allowed to snip away bits of the yellow, gooey fibrinous exudate that we wanted to eradicate. But even after we cut away as much as we could, there were little bits still stuck down, too small to remove with scissors. So we (that includes me!) used another tool.
Before we started with it, the resident picked up the handheld device, and asked me what I thought it was.
“Well, it looks like a water gun,” I told her.
She told me that’s essentially what it was — a combination water gun and suction device. It sprays a high-powered stream of water into the wound, loosening the remaining gunk, and simultaneously sucks it up.
The resident then pointed to a shield surrounding the nozzle.
“This is to keep us from getting sprayed,” she said. “Don’t spray us.”
Then after a brief demonstration, it was my turn. I considered my time with the fancy water pistol a full success: I helped clean up the dead tissue, and I avoided spraying my resident and intern in the face. Even with our eye protection, that would have been … less than ideal, to say the least.
The ulcer debridement was a procedure I had really wanted to scrub in for. Having talked so much with my mom, a hospice and palliative care nurse, about wound care, I wanted to see it in action.
Along those same lines, it was interesting for me to see bedside wound care too. Several times last week, I went along with an intern to change a dressing. The intern did most of the medical work. My main role was to distract the patient from the pain, inevitable in spite of pre-medication. So I put my palliative care hat on, glad to help ease a patient through this temporary, painful event.
More than once, an intern has apologized to me that there isn’t anything “interesting” going on for us to see. The intern was referring to the fact that some days, there are few, if any surgeries going on while us medical students are there. On the other hand, there are also days when we’re booked back-to-back, plus emergency add-on procedures. You simply never know. My response is always that (of course!) while I’m excited to scrub in for surgeries, I’m also just glad to be part of the team, helping with the little things like gathering supplies for a bedside dressing change or procedure.
It’s all part of the learning process. And that’s why I’m here.
*s/p, which stands for “status/post,” essentials means “after.” It’s often used in reference to procedures, such as surgeries. For example, a patient who had their gall bladder taken out 5 days ago would be referenced to as “s/p cholecystectomy 5 days ago.”