Sunday call

There is nothing quite like a morning amputation to make your day feel productive. By lunchtime you have already rounded on all the patients, redressed the wounds, updated the orders, written progress notes and removed a person's limb. Call it macabre, but that's a lot of to-do list items checked off.

Amputations feel so satisfying because you can physically see the work (unlike a stent or graft where all the work is interior). They are also extremely quick surgeries; you bove through the skin/muscle, saw through the bone, clean up the edges and sew a skin flap. Done and done. From induction to reversal, taking off this guy's forefoot took one hour. And yes, they let me cut through some bone. There was a lot more spatter than with the above-the-knee I did last week. This time I had blood spray on my goggles and mask (cool).

The picture is an x-ray s/p (after) a transmetatarsal amputation. People lose their forefoot and have special shoe inserts that help them with ambulation.

There is another guy on the floor at the moment who had a bypass graft done earlier this week. It's a high risk graft, which means there is a strong likelihood the graft will clot off. More of a when than if. To extend the life of the graft we put the patients on coumadin. Well, this guy really doesn't want to take it in case it causes some nausea. SERIOUSLY? How is this a decision? Take the coumadin +/- a anti-emetic and keep the leg for a few years vs. don't take coumadin and lose the leg in weeks. He has to think about this?

Tidbits

1. Standing in the OR holding a freshly amputated leg (above the knee) and putting it in the disposal bag. When you take something off the table, you have to call out. Examples include: knife down, needle back, etc. Handing off the leg, I stated "one partially used limb for pathology."

2. Putting stitches into a femoral artery graft. They have to be perfect because you don't want the patient bleeding from the graft-artery junction (anastamosis). The attending let me throw the last 4 to close the anastamosis. The needle we use is less than a millimeter thick and 1cm long. We took the clamp off and... my sutures held!

3. A patient on the thoracic service was bleeding through his dressings after having an emergent bilateral fasciotomy (two big incisions in each leg, left open) earlier that morning. The interns were busy dealing with a patient having a heart attack so they sent me down to do the consult. The fellow and attending agreed with my plan and had me present to the primary team. The nurse didn't want to touch the dressings so I redid the surgical bandages (more complicated than just some gauze), stitched his central lines in place, then answered the wife's questions. Basically, I acted as the consulting resident from vascular (quite a promotion).

4. Putting a Foley in a man with a penis that is permanently fibrosed in the erect position.

bad days

I'm coming to the conclusion that when choosing a specialty, you need to choose the one where even the bad days are somewhat fun. I don't mean bad as in the previous post where you're emotionally drained; I mean bad as in technically the sh*t is hitting the fan. An example of one of these painful days...

I got to the unit at 5:30am for pre-rounds, as usual. I checked in on my patients and took down the dressings, as usual. We rounded as a team and I re-dressed the wounds, as usual. There was no morning conference so I headed down to the OR early to put in the patient's Foley and watch anesthesia place the central lines. The planned surgery was an open (cut the abdomen open, rather than inserting a catheter though the vessels) abdominal aortic aneurysm repair. It should take 4-5 hours. I was scrubbing with the uptight fellow and one of the old Spaniards.

The case began and he was a little wetter (oozing blood) than expected, but otherwise the dissection to the retroperitoneum was uneventful. We were able to clamp infra-renally (good) and got proximal and distal control of the arteries near our anastamosis sites. We began grafting to the aorta, but the clamp appeared through the posterior wall. This means the aorta had torn, so we had to reclamp, higher, and get control of the bleeding. We managed to get the graft on, but the patient was still bleeding. We discovered the aorta had torn proximal to the clamp. We attempted to mobilize the aorta and sew the tear closed, but it continued extending. It look 3-4 hours and a supra-renal clamp to repair the tear. We turned our attention to the iliac anastamoses, and one of these also proved problematic with excess bleeding. We finally closed the belly to find he had stopped urinating and had stooled all over the OR table. At this point he had lost just over 13L of blood.

We did dopplers of his feet to check for pulses and found one limb to have absent pulses and pallor. We prepped for a thrombectomy, to extract the presumed clot released when we came off the aortic clamp. Once in his groin, we found very calcified arteries and insufficient forward flow to float a catheter down the leg. We immediately converted to a femoral to femoral bypass graft. We opened the other groin and reheparinised him. The bypass was completed uneventfully and his groins were closed. At this point, he had another 2L of blood loss.

The whole operation took 14 hours (I was allowed to leave at hour 12) and ended up being really rough on his kidneys (suprarenal clamp) and having a very long aortic clamp time (no fresh blood to the legs -> tissue loss -> also bad for kidneys). He's stable (for now) in the ICU. The point (long-winded, yes) is that this was a tough case where everything was going wrong. This is a painful surgery, even for a surgeon. In fact, the attending that started the case was not the one who finished it. If you can still find some fun in this kind of day, then maybe the OR is the place for you. Me, well, I did not find so much fun in this. But there are rough days in the ICU I get some rush from. Where the fight is energizing as well as draining. So I don't think I'm a future surgeon, but I think I earned some respect from them for standing in that OR for 12 hours with no food/water/peeing/sitting.

We all fall down

Well, I suspected it would happen, but surgery broke me. On Friday night I was reduce to tears. Or more accurately, collapsed sobbing on my bedroom floor. It was, in all honesty, a pathetic sight and a definite low-point. How did this happen? Well... Friday actually started out quite well. Rounds went relatively smoothly since we had the relaxed fellow. Then it was off to clinic with the nice attending. The first two patients didn't show so I was able to grab a coffee and tend to some email. I managed to see six patients and write their notes before leaving for seminar, prompting Dr. E to tell me I was "ready to be a fourth year." So yeah, the day started out fairly well. Seminar should have been a hint. It was about our future, a topic that always give me a little spasm of fear: will I be able to match to geography I like given my Step 1 score? Am I going to get stuck doing primary care in Idaho? A classmate approached me during seminar to tell me that the uptight fellow had scrubbed on some cases at the VA with him and spent the time in the OR asking my fellow student pointed questions about ME (unprofessional!). He couldn't say anything nice (what?) so he lied and said he had never been on service with me (thanks). I got back to the conference room after seminar in time for afternoon rounds. When the other students on vascular got back they made it clear I shouldn't have left without them (they left without me last week). Off to teaching rounds with the over-enthusiastic attending who pimped JUST ME on surgical abdomens, but felt the need to stop halfway through to tell the whole room that I was defensive and arrogant and should get that under control (unprofessional!). After teaching rounds the two medical students on vascular cornered me to have a frank talk about how I interrupt too much. I then took some staples out of a woman's abdominal wound and was allowed to leave. I got out of the hospital into the freezing air and tears started sprouting. Trouble is, they started freezing in my eyelashes as I walked. Yes, I froze my eyes shut crying on the walk home.

So let's reflect: yes, the "constructive" criticism I received is grounded in truth. My board scores are my fault. I am defensive, but not out of arrogance. I hate getting things wrong because I'm terrified. I probably do interrupt too much, but could that conversation possibly have waited until the next day given they had just watched me get humiliated by an attending? Not to mention that I have not committed the cardinal sins of throwing another student under the bus or claiming all the good surgeries?

End result: I don't have skin thick enough to be a surgeon. Nor do I want to. I do take it personally when people criticize me; because I care. I care that I'm good at this and that I am respected. I don't want to become the kind of person who can humiliate another person in public just because they can't talk back for fear of their grade. It does not help my learning. Being a good teacher is about motivating and empowering, not belittling and intimidating. Surgeons seem to confuse fear with respect.

A clue, sherlock?

The big decision: internal medicine vs. pediatrics.

While on call on Friday I was with my team (vascular surgery, at the moment) on evening rounds checking on patients before we more or less leave them alone for the night. One of our patients was a young boy, so we had to trek over to the children's hospital to check on him. On entering the pediatric intensive care unit, I got this little stomach flip-flop. That little bubble of abdominal excitement you get when you're about to open a present or buckle yourself into the rollercoaster with 7 loop-de-loops. I wonder if that fleeting visceral excitement is a signal from my subconscious telling me to be a pediatrician?

Surgery begins

On Monday I began my vascular surgery month. It's now Wednesday night and I have already worked 31.25 hours. They have us track because we aren't supposed to go over 80 in a week. Legally we can, but they don't want us to have it worse than the interns. How generous. Not that they would actually send us home if we hit 80; they just want to know.

Regardless, I spent day 1 in lectures and the simulation center; days 2 and 3 involved rounding and then hitting the OR. The OR is an interesting mix of incredibly cool and unbelievably boring. There are moments when you are helping, being quizzed (or taught) or watching something insane. Those are the cool parts. Then there are long stretches of time when you are largely ignored, uninvolved and staring obliquely at something which is probably an organ or blood vessel. You try your best to stay out of the way, remain sterile and ignore the aching in your back and feet. And the fact that you are hungry. And need to pee. Those would be the boring bits. Thankfully, the vascular attendings are somewhat more enthusiastic about teaching than reputation would have you believe and they like playing music and cracking jokes in the OR. This helps the time move more quickly.

In fact, one of the patients today was under sedation (rather than anesthesia and thus is partially awake) and requested Barry White be played. We complied and he sang along! This while we were debriding his horrendous foot ulcer and stenting open his right leg arteries by sending a catheter down his left arm. Bonus, one of the nurses showed me where she keeps her stash of peanutbutter Dove chocolates... score!

them apples!

Is it just me, or have apples become ginormous?

Hace calor. Hace sol.

I have returned from a two week trip to Argentina. Amazingly, this is the only true vacation I get between May 2010-Dec 2011. Yay medical school. Anyway, I returned from a trip to El Calafate and Buenos Aires. Unfortunately time did not allow me to see Torres Del Pine and circumstances prevented a side trip to Colonia, Uruguay, so those will have to be accomplished in a subsequent trip.

In El Calafate we hiked the Perito Moreno glacier; first an hour along the lateral moraine, then four hours on the accumulation zone (complete with crampons) before hiking back out along the lateral moraine again. It's impossible to capture the scale of the glacier with photographs. The weather was fantastic; I did the second half of the hike in just a long-sleeved t-shirt.

We also hopped onto some horses to see the surrounding countryside, which is practically an iridescent shade of green. It's complete with wild llamas and plenty of space for a good gallop or a cozy lunch of steak, onions, wine and havanas.

Back in Buenos Aires we did a little going out, a little cultural enrichment and a lot of reading and relaxing. And eating. There is a lot of great food (especially ice cream), but interestingly, no peanutbutter to be found. Anywhere. There might have been a little shopping in there too.

Going out in Argentina is a bit crazy because, in general, dinner is between 9-11pm. No one arrives at the bars or clubs until 2-2:30am and then people stay out until sunrise. Needless to say, that's not my usual schedule so it took a little adjusting too. As did coming back (to surgery and 5:15am pre-rounds). We went to a local, unmarked bar to shoot some pool, a swanky foreign bar, spent a night learning to tango and hit up a hip-hop club, complete with break dancing and dance crews.

Overall, I was surprised by how European the city is and how good the English is (although a friend who was also there said he had more trouble with the level of English). It's definitely a place I would enjoy returning too and there are plenty of stunning landmarks I missed: Mendoza (wine country), Iguazu Falls (natural wonder) and the previously mentioned Torres Del Pine. It also reinforced the fact that I absolutely must learn Spanish. It is an extremely useful second language in medicine and in travel.