doc w/ Pen

journalist + medical student + artist

Tag: surgery

Weird surgery perks

Beneath my white coat, you can see the maroon OR scrubs that I wore every day while on my trauma surgery rotation. Wearing these scrubs every day provided an unforeseen benefit: less laundry to do.

My enjoyment of this surgery rotation thus far has been a pleasant surprise. Besides learning about, well, surgery, I have encountered important life lessons. But I have also accrued some unforeseen benefits. I think that understanding these perks will provide additional insight into what life is like on the surgery rotation.

Chore relief. On trauma surgery, you wear scrubs all day every day, with the exception of Monday morning’s Morbidity & Mortality conference. That meant I had less laundry to do. Given that I have to lug my dirty clothes up and down several flights of stairs and down the block (I’m in a walk-up apartment, and the laundry room is in the basement of a different building), that’s no small thing.

Budget boost. When I was working with the trauma surgery team, I would leave my apartment at 5 a.m. and get home somewhere between 6 and 8 p.m. That’s a long day, by any standards. I noticed that over four weeks of that schedule, I bought significantly less toilet paper. Actually, my grocery bill was lower overall. I was so busy that I simply ate less. In part because the workday on surgery was so hectic, and in part because when I got home at night I was too exhausted to do more than shove some food in my mouth and collapse into bed.

Free medical supplies. Yesterday, while I was cooking a batch of chili, I managed to slice open my thumb on a can of diced tomatoes. I ran to the bathroom, thrust my thumb under a stream of running water, and scrubbed the cut with soap. Before reaching for the box of Band-Aids in my medicine cabinet, I turned to grab a Kleenex to dry my finger. Then I remembered that I had something much better — sterile gauze! A packet from the hospital had made its way home in my white coat pocket. Hm. Maybe I should grab some more?

I wouldn’t consider these reasons to do a surgery rotation, exactly. But since surgery is a medical school requirement, I certainly won’t turn down the random fringe benefits.

A newly prudent pedestrian

Medical school is one of the most intense experiences I can imagine. As such, I expected it to change me. It has. And in some unexpected ways.

On a recent summer evening, I walked some 15 blocks to a Thai restaurant to meet a friend for dinner. It was a lovely evening. I enjoyed the fresh air after spending so many hours cooped up in the hospital over the last several weeks. On my walk, I noticed something. Since completing my four-week trauma surgery rotation, I’d become a much more cautious pedestrian.

When waiting to cross a street with lots of traffic, I didn’t tip-toe into the street, or even stand at the edge of the curb. Instead, I hung back a few feet. I still jaywalked, but only if there were absolutely zero cars in sight. None of this dashing across the street to beat an oncoming vehicle. And when I saw someone else do that, I shook my head (literally). Even when simply walking on the sidewalk, nowhere near an intersection, I found myself paying close attention to the traffic running parallel to me — something I’d never really done before.

I had abandoned my aggressive pedestrian stance because darting into traffic saves you no more than a few seconds, and can cost you so much. I paid more attention to my surroundings because even when you’re on the sidewalk, minding your own business, a car could jump the curb and smash into you.

Technically, legally, pedestrians may have the right of way. But legality melts away in the face of a 2-ton steel monster barreling toward you.

That reality is now all too clear to me. While on trauma surgery, I’d seen too many pedestrians hit by cars. In medical lingo, this type of trauma is referred to as a “pedestrian struck.” Often the collisions resulted in simple lacerations or minor broken bones. But sometimes they resulted in coma, intubation, and craniectomy (removing part of the skull to relieve elevated pressure in the brain).

Maybe increased caution and attention won’t make being a pedestrian in New York City much safer. But they make me feel better. And that’s something, I suppose.

Four weeks of trauma surgery: lessons learned

Friday marked the last day of my four-week rotation on the trauma surgery service. As expected, it was an exhausting four weeks. But it was also incredibly exhilarating and educational. And it was filled with many profound moments that will stick with me forever.

This, in large part, was due to working with such a phenomenal team: An attending who taught me that if a trauma surgeon can take 10 minutes to sit down and talk with a patient, every physician should have time to do so; who inspired me to learn and ask questions; and who made me excited to go to work every day — even when that meant waking up at 3:30 a.m. A chief resident who carefully followed a patient’s blood tests after I got splashed in the face during a case, and personally kept me updated. A senior resident who was willing to put a nasogastric (NG) tube down my nose and throat because I wanted to know what our patients with small bowel obstructions were going through. (I’ll be writing more on that soon.) Interns who clearly wanted these four weeks to be an educational experience — and proved it by inviting us medical students to practice starting IVs on them. A fellow medical student, one I barely knew going into the rotation, who quickly became a confidant.

These are just a few examples of how my team helped make the oft-feared surgery rotation such a meaningful experience.

In medicine, you learn from your team. You also learn from your patients. Working on the trauma service for four weeks, I am now acutely aware of how a person’s life can be permanently changed — or even snuffed out — in the blink of an eye. I helped care for patients whose legs were now useless after a car crash, a gun shot wound, or even a freak fall from standing. “Pedestrian struck” was another too-common reason for admission to our service. Usually, the result was a laceration or some broken bones — things that were painful, but that would heal, with time. But sometimes the trauma of being hit by a car results in a brain bleed. Sometimes these resolve. But sometimes, they result in irreversible brain damage, or death. All because you were walking on the sidewalk, or crossing the street, at the wrong place and the wrong time. This hits especially close to home when the patient is close to my age, or reminds me of someone I know. This could happen to me. It could happen to any of the people I love. As could appendicitis, cholecystitis, or a small bowel obstruction — three other very common complaints I’ve seen on this service.

So as I interact with patients and their family members, I attempt to do two things. I first try to put myself in their shoes, as best as I can. This helps me understand (and if needed, forgive) any angry outbursts or other nastiness. It’s not personal. Second, I do my best to treat the patient, and the patient’s family, like they were my own family. I would want a doctor, nurse, or medical student to treat my parents, sisters, or friends that way. One of the trauma attendings modeled this behavior so well. When patients and their families thank him for his kindness, he tells them outright that his goal is to treat people like his own family. I’ve taken to doing the same.

These are not lessons I necessarily expected to learn on my surgery rotation. But they are important lessons that will remain with me, whatever I do in medicine.

Don’t get me wrong — I learned about surgery on my surgery rotation too — suturing, knot-tying, and so on. But I could learn those things from any surgery attendings or residents. My team helped teach me so much more.

s/p surgery rotation, week #1

My 6-oz. water bottle, which fits in my white coat pocket, helps keep me hydrated throughout the day. Its small volume keeps me hydrated enough that I don’t get lightheaded, but not so hydrated that I have to go to the bathroom all the time. In surgery, hydration is a delicate balance.

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.

I’ve found several flavors of KIND bars (high protein, lower sugar) that keep me fed when there isn’t time for a real meal. String cheese is great too.

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, 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.”

Surgery, day #1: attitude adjustment

We weren’t wearing the appropriate maroon scrubs when we went to the OR to practice how to scrub in for surgeries. So we had to don the infamous blue “bunny suit.” These disposable, zip-up onesies are only stocked in XL, so most of us looked completely ludicrous. I felt it was important to capture the ridiculosity of the moment. My friend, who had kept her iPhone handy, was kind enough to oblige.

Around the country, the medical school surgery rotation has a reputation for being one of the toughest and most grueling. The hours are long, the breaks are few, and the expectations are high.

So it was with more than a little trepidation that I approached the first day of my surgery clerkship yesterday. But after yesterday, I find myself with a changed attitude. The hours won’t be any shorter, but our day of orientation got me excited about what I’ll be seeing and learning over the next 8 weeks.

Our orientation included the obligatory lecture sessions about clerkship logistics, leadership, grading, safety, all that. But after those things were out of the way, we got to do stuff. Fun stuff.

Our orientation was held in Weill Cornell’s Skills Acquisition and Innovation Laboratory (SAIL for short). It’s a suite of rooms in the hospital designed to help surgeons, surgical residents, and medical students practice their surgical skills. And while as medical students, we obviously won’t be performing the operations, we will be assisting in some ways. Depending on the trust earned with our residents and attendings, we may be asked to do things such as insert the foley catheter (for urine), retract, hold the camera during laparoscopy, suture, and tie knots. Retracting is pretty self-explanatory, but everything else requires some knowledge.

So yesterday, we practiced. We used actual foley catheter kits (the same kind that we will see in the operating room) on both male and female mannequins. Urine passage is obviously pretty different depending on the gender, and getting a tube up there is also a little different. While inserting the foley, we worked to maintain sterile technique to reduce the risk of infection. There were also workshops on knot tying (so many knots to learn!) and suturing (so many ways to suture!). The most high-tech workshop was for laparoscopy, also known as minimally invasive surgery. That’s where they make tiny incisions and insert a camera and other instruments rather than open up the abdomen (or other part of the body) with a long incision. There were several stations to practice our hand-eye coordination. It was a lot like playing a video game. At each station, you looked up at a screen (same as you’d do during a laparoscopic procedure) while holding the camera and/or instruments with your hands. Then you had to manipulate objects with your instruments, passing tiny blocks from one hand to the other, dropping beans into a tiny hole, or untangling rope (to simulate loops of bowel), for example. These stations actually replicate an exam that surgical residents have to pass in order to graduate. After doing a few stations, I have a new respect for this kind of surgery. I did notice improvement after a few go-rounds though, so I see how these practice stations are a huge help to surgeons.

Late afternoon, we headed to the OR for a brief tutorial on scrubbing, gowning, and gloving. Since I completed my ob/gyn rotation, I’d already learned these skills, though it was a good refresher.

At the end of the day, I’d recalibrated my attitude. And I’d formulated my goals for the clerkship. I want to perform well, of course — that goes without saying. That overarching goal encompasses lots of little goals, including studying for the shelf exam, reading up on patients, being a helpful student, working hard on my patient presentations, and so on. But I also want to leave surgery with a better grasp on some of these surgical skills, particularly suturing and knot tying. We were told yesterday that it takes (literally) thousands of hours to really learn how to suture and tie knots. I don’t have thousands of hours to practice. But I also don’t need to perfect my skills to the level of a surgeon. I do, however, want to feel more comfortable doing those things, because they’re useful across the practice of medicine. So I talked at length with the doctor who runs SAIL, which is open 24/7 for us to come in and practice. I’ve now got some sutures, gloves, and other paraphernalia at home to practice with. And he told me to come back in a week or so to show him my progress. He’ll help me if I’m struggling with anything or if I’m doing something incorrectly — both of which are very likely. I know that this kind of hands-on tutoring is invaluable when learning a new skill. I’m so grateful for the help.

Along with being a writer and medical student, I’m also an artist and former pianist. I love using my hands, and know the importance of building muscle memory. So I see this as a fun (and practical) challenge.

I love a good challenge. I’m in medical school, after all.

Getting back up

In addition to sharing my experiences here on this blog, I write a monthly column for the online magazine The American In Italia. This month’s piece, published yesterday, is about how humbling medicine is — in more ways than I expected. Here’s the link: Getting back up.

Caution: sharp objects ahead

When you call it a "butterfly needle," it sounds so innocent and cute ...

When you call it a “butterfly needle,” it sounds so innocent and cute …

One step closer.

That’s what I tell myself with each new medical school milestone. This week, there were two big ones. Both involved sharp objects. But with the exception of some minor bruising, everyone came out just fine in the end.

Monday, I took my first stab at drawing blood (that pun was so intended). I’ve done delicate surgical procedures on mice, including injecting medication into the inferior vena cava. But survival was not a goal of those procedures. Phlebotomy is obviously much different. This first time, we medical students practiced on each other. With some guidance, my classmate stuck me on her first try. I had a little more trouble. Three pokes later, I managed to see the coveted red flash of blood. I patted myself on the back until I saw my friend the next day. When asked, she showed me her arm — a purple bruise where I’d poked.

I’ll get better. It takes practice, just like everything else.

Suture kit

With suturing, you use metal tools to hold the needle and the skin.

Though it was technically my first time with this too, Tuesday’s activity — suturing — actually felt less foreign in some ways. I learned basic sewing when I was in elementary school. I feel comfortable with the general act of guiding a needle and thread. With sewing though, you use your hands to hold the fabric and the needle. With suturing, you use metal tools to hold the skin and the needle. That took a little adjusting.

Another adjustment: it took me a moment (and a comment from a surgery resident on my crazy stitches) to realize that while sewing and suturing share many features and movements, the basic suture technique I was practicing differed from sewing in one very important way. With sewing, you create contiguous stitches to keep the fabric together. You tie a knot and cut the thread only when you’re done, or when you’ve run out of thread. With the basic suturing technique I practiced Tuesday (called the “simple interrupted suture”), you create distinct stitches that are separate from each other. Stitch, knot, cut. Repeat.

This makes sense. Fabric needs that continuity to stay together. With skin, you’re holding things tight temporarily, just until the skin gets its act together and heals itself. Then you don’t need the stitches anymore. The simple interrupted sutures are actually a lot like straight pins in sewing. When you hem a dress, you pin it up first to keep everything straight and tidy. Then you run it through the sewing machine. Once you have that strong hem sewn, you remove the pins. Likewise with the simple interrupted suture I learned: you put temporary, individual sutures in until the skin is healed. Then you pull out the sutures, just like you did with the pins of your dress hem.

It makes sense to me now, but my practice foam block (full of contiguous sutures) must have looked like a complete train wreck to that surgery resident. Well, now I know. And more importantly, I understand.

Knowing, understanding, practicing: this means I’m headed in the right direction. Even if I did leave a little bruise.

A Hamburger, and a Lesson About Medicine

Last Friday I learned an important lesson about being a doctor – at Five Guys Burgers and Fries.

I was waiting at the counter for my order. Standing next to me was a woman, probably in her 60s, with a walker, also waiting for her food. There must be something about me that looks friendly, because this woman started a rather personal conversation with me. I’d had a rough day, wasn’t really in the mood for chatting, but I could tell she needed someone to talk to. So I listened. The woman told me she’d had heel fusion surgery around Thanksgiving, and was very unhappy with the result. As I listened, I realized it wasn’t the actual result of the surgery that frustrated her, but it was the disconnect between the surgeon’s optimistic attitude and her realistic outcome.

I know there are two sides to every story, and obviously I haven’t heard the surgeon’s side. So it’s quite possible that back in November, when she and her surgeon were discussing the surgery, she heard what she wanted to hear. Her take-home message from those conversations, though, was that by June she would be wearing summer sandals and walking normally. “Instead,” she told me, “I will be wearing a brace that goes halfway up my leg.”

I don’t know for sure, but I think the woman would have been less angry if she felt she had gotten a more realistic prognosis from her doctor. True, it is important for physicians to give their patients hope. But it has to be an honest hope. As a doctor, I think you have to present the various scenarios that could  happen. Not to frighten your patients, but to prepare them.

It’s a fine line to walk, clearly. Optimism and hope can motivate a patient to work harder, to believe he or she can get better. But if you only present the best case scenario, you run the risk of angering your patients, of losing their trust. This woman didn’t say so directly, but I could imagine her considering a lawsuit against her surgeon. Not because he botched the surgery, but because she felt lied to, misled.

As I said, I don’t know the whole story here, so I am certainly not passing any judgment on this surgeon. It could very well be that this woman completely misunderstood what he told her. And as a doctor, you can’t control what patients decide to believe, or what they choose to hear. Even so, I think it does fall on the physician to do all he or she can to present the situation honestly to the patient. With optimism, yes. But also with realism. Because once that trust between a physician and patient is broken, I think it is very difficult, if not impossible, to repair.

New [Mouse] Surgeon on the Block

Until a couple of weeks ago, I had mainly been doing genotyping at my lab job. I’ve got it down to a “science” (pun intended). I’ve been getting great results, which is wonderful. But I was itching to learn some new techniques. Well, I’ve gotten my wish.

My supervisor is teaching me animal surgeries. She has dozens of these to perform in the coming weeks and months, and wants someone to help reduce her load. And of course, I’m thrilled to learn something so practical for my future career as a physician-scientist, especially given that the mouse is the most frequently used animal model for diabetes research, which is what I want to do.

The first technique I learned (and am now pretty good at) is called an ELW (Excess Lung Water) procedure. It involves nebulizing mice with LPS, which basically gives the mice a septic lung infection, and then measuring various aspects of their lungs and blood. The most difficult part is taking a blood sample from the inferior vena cava, which you can imagine is pretty tiny in a mouse. And given that I’ve never really handled a syringe before, getting that needle in and then pulling the plunger back (with the same hand) was at first a challenge. But Thursday I performed my first ELWs on experimental, as opposed to practice, mice, and all went relatively well. (Except for one thing, which I will talk about in another post.)

The other procedure I’m learning is much tricker, and I’ve only mastered the first half. The purpose of it is to clear the mouse’s lungs of blood so they can be used for other experiments, such as histology, sectioning, etc. Cutting out the lungs is the easy part. The more difficult parts are putting the mouse on a ventilator (yep) and catheterizing the heart. Getting the mouse ventilated involves cutting part way through the trachea (again, quite small in a mouse), inserting a trach tube, and then hooking that up to a ventilator machine. The hard part is all the manipulations you have to do with your forceps prior to getting the trach tube in – for example, getting the 90-degree forceps under the trachea without causing the mouse to go into tracheal spasms (so you can pull through silk thread to eventually secure the trach tube). At first, I really struggled with getting that trach tube in. But I am quite good at it now, which is very exciting progress for me.

After getting the mouse on the ventilator, I heparinize the mouse to prevent blood clots, again through the IVC. Not that bad, considering I now am pretty decent with the ELWs. Another challenge after heparinization is catheterizing the heart. A mouse’s heart is literally the size of my pinky fingernail (and I have small hands). You have to get silk thread under the pulmonary artery, cut off half of the atrium, cut the aorta/IVC, and then slice slightly into the left ventricle to insert a small catheter. You then feed the catheter up the heart, into the pulmonary artery, so the fluid (PBS) going through the catheter will clear the lungs. This part of the procedure I am not so good with yet, but I am making progress. “Paso a paso,” one step at a time.

It’s slightly amusing to me that I am doing these procedures, and really enjoying learning them, given my past history with animal dissections. When I was a kid in homeschool, my mom would go to the butcher and get meat remnants (eyeballs, a pig head, various organs) for us to dissect. My sister would totally go to town with them, using a surgical kit that my dad, a physician, lent us. I wasn’t afraid of the dissections, but neither was I interested in them, so I hung back, watching. Now I’m totally into it, and thrilled to be expanding my skill set, as well as becoming more useful in the lab.

Shadowing: Open Heart Surgery

Yesterday, I shadowed an anesthesiologist friend of mine. I had shadowed him before, and seen some amazing procedures, both in terms of the anesthesiology and the surgery. But this time was the best by far. I got to see a fascinating cardiac case — open heart surgery. It was a complex case; a double valve replacement (mitral and aortic) and a valve repair to boot (tricuspid).

heart ultrasoundOne interesting thing was that before the surgery, they weren’t entirely sure whether they were going to be repairing the tricuspid valve. So the anesthesiologist did an echo by sliding a probe into the patient, near the patient’s heart, and rotating the probe to look at the different valves on a screen. He could also turn on a blood flow feature, which showed us different colors, each color illustrating a different blood velocity. This allowed us to see whether there was regurgitation, aka “regurg,” which there was, from all three valves in question. (The image of a heart echo here shows mitral regurgitation, or blood flowing in the wrong direction, similar to what this patient had.)

During the surgery, I was on the anesthesiologist’s side, behind the surgical curtain. But they got me a step stool so I could peer into the field. I did this during almost the whole surgery, with the exception of a quick lunch break. I watched the initial incision, the cracking of the rib cage (with a giant chisel!), the separating of the pericardium from the heart, cutting into the heart, the placement of the valves. It was amazing to see a live, beating, human heart just a foot or two away from my face. And then suddenly, it was no longer beating, as they had put the patient on bypass to do the more delicate parts of the surgery (the valve replacements and repair). They cooled the patient’s body to 25 degrees, and literally bypassed blood flow to and from the heart, oxygenating the blood with a perfusion machine and returning it to the body via tubing. They also used a cocktail of compounds (including potassium) to keep the heart from beating during that time.

It was a long surgery; around five hours. (And this does not count the time the anesthesiologists spent prepping and anesthetising the patient.) I felt privileged to be able to see how modern medicine has made such a procedure possible. And so incredibly ready to start medical school …