Les sons et les parfums tournent dans l'air de l'O.R.

The linoleum floors of the hospital corridor are polished with some lemon and pine concoction. As I approach the cul-de-sac of operating rooms, this clean scent gives way to that generic sterile smell that all hospitals have. The hustle and bustle of stretchers and food carts and medical supplies rumbling through the hallway fades upon entering the OR suite.

Voices in the OR mingle - some comforting the patient, others giving instructions for the room setup. Soft clinking tickles the din as the scrub nurse organizes the sterile instruments on her table. Iodine cuts through the air as the circulating nurse sterilizes the surgical site. Ruffles ensue as the patient is covered with layers and layers of surgical drapes. The heart monitor provides a metronome beat with its steady electronic beep.

At last, the surgeon announces the start of the procedure with a simple: "Knife." The blade cuts the skin without effort - it seems there should be a sound with this action, but there is none. As soon as the incision is made, the surgeons dig deeper with an electric cauterizer, searing away the underlying superficial fat - snap crackle pop! Gray wisps of smoke waft from the body cavity and the smell of fried gristle permeates the room. Not altogether unpleasant, but not exactly hunger-inducing, either. The surgeon calls for the rib cutter - it opens up the chest wall with a wet crunch.

For the duration of the operation, all that is heard is the beeping of the heart monitor, bits of chatter, and the occasional clang! of an instrument being dropped onto the floor. And perhaps some med student snoring. (If a med student keels over in the OR and nobody's paying attention, does it make a sound?)

When the work is done, the sounds seem to happen in reverse - ruffles of drapes being taken away, instruments clinking as they're put away for another day, nurses counting sponges, the hisssss of oxygen flowing into the breather mask, the anesthesiologist pleading with the patient to "Wake up!!!" The patient is moved onto a stretcher with a schrumpf of sheets covering a heavy body, then the stretcher rolls and creaks away. The cleaning crew enters to end the dance, their wet mops slapping the floor wiping away the blood and guts.

Their role complete, the crew files out of the room, snapping off the lights, the room ready for the next dance.

Further Foibles in the Operating Room

Surgeons can be curious folks - at least, they're reputed to be rather intense. One common description one would hear bandied about the hospital floors is that some individual exhibits "the classic surgeon's personality." Never used as a compliment. In reality, I think surgeons are pretty much like any other group of people - a mixture of cool, laid-back, intense, and, yes, some classic surgeon's personalities. I was warned of one such individual before I started Orthopaedics, "Dr. Jayne."

Dr. Jayne, I was told, would not even lower himself to speak to a medical student. You could offer him your hand when you introduce yourself, but he'd ignore it and walk right by you. The first time I see Dr. Jayne is during morning rounds when the Orthopaedics residents present the most recent cases to the surgeons. Dr. Jayne sits in the front facing the X-ray films, with his back to everyone else. He never turns to face the other people in the room. He rarely says a word. Once the presentations are over, he gets up and walks out of the room never making eye contact with anyone. Yeah, I'll try to introduce myself and shake his hand, all right. In Hell.

Naturally, I'm scheduled to be in the OR with Dr. Jayne. He sets up his OR with meticulous detail, instrument tables, portable X-ray, and people all centered efficiently around the patient. He is able to communicate even without moving his eyes. He says all of two words to me directly during the four-hour procedure ("Watch out"), and that was to get out of the way of the X-ray machine that was coming in to check the alignment of the patient's bones. Other than that, Dr. Jayne uses silent communication to instruct me. At the two hour mark Dr. Jayne breaks scrub and takes a half hour break. When he scrubs back in, he just walks up to me, still not making eye contact, and hands me the tag from his operating gown so he can tie himself back up. Aha! At least he knows that I'm standing in the room. I consider this an enormous success and plan to reward myself with an extra 15 minutes of sleep that night.

Dr. Jayne is in absolute total control when in the OR. Nobody moves without his permission, and he essentially performs the entire operation. Even the senior resident has a minimal role in the procedure. I do manage to get my hands dirty, though, when Dr. Jayne speaks (without looking up, of course): "And [muffled] would hold the retractor down here..." I'm so impressed with myself - OR time is approaching 4 hours, my presence has been all but ignored, and I'm still paying enough attention so he doesn't have to repeat himself.

In contrast, I assist the Chief of Orthopaedic Surgery in the repair of a hip fracture. Dr. Emery isn't even in the room when the operation starts - he allows the Chief Resident to set up the room and begin the dissection. The Chief Resident, Anthony, allows me to do so much more, like cutting the skin and the underlying fascia, feeling the fractured ends of the femur, cauterizing any bleeding arteries, using any number of doohickeys for retraction, and another doodad to guide cables around the bone to hold the reduction in place. Luckily, I don't have to know the names of all the other whozeewhatsits and thingamabobs and whatchamacallits on the instrument table. That's like surgical resident knowledge.

Dr. Emery steps in for the most important part of the procedure, fixing the bone in place, then breaks scrub. He places total trust in Anthony. I expect to be pimped, and Dr. Emery fixes his gaze upon me:

Dr. Emery: Where are you from, Mike?
Mikey: Pittsburgh. (yippee! First question right. I so rock.)
Dr. Emery: Ah, Pittsburgh - do you know Dr. Fu?
Mikey: Yes, um, I know of him.
Dr. Emery: Do you watch 'Big Love'?
Mikey: No, but I've watched Six Feet Under...
Dr. Emery: Ahhhh....Six Feet Under. Great show. Big Love is probably just a little bit better.
Mikey: I'll keep an eye out.

Okay, so that wasn't really being pimped by any measure.

Anyway, Anthony lets me help him stitch up the patient. Hilarity ensues. Even the anesthesiologist is giving me pointers. I need to practice. I think, however, for my first time stitching up a real live person, it was a success in that I didn't sew my own fingers to this lady's leg.

Coming soon: Mikey practices his surgical knot tying, successfully saving the lives of an orange and frozen pig feet. Or not.

Overnight Call

'Call' is one of those words that, if you say it repeatedly, starts to lose its meaning. I can attest that about 3:30 in the morning, most things start to lose meaning. And one starts to question whether one was meant to be in this medicine business.

I feel like I've been struggling to make an impression with the residents on the Orthopaedics service. Part of it is because they've sent me to the OR a couple days, where I interact with only one resident, or I've been scheduled for a clinic that didn't happen, or I've got some reading time. So I figured I'd change things up a bit by opting to stay with the on-call team Friday night. I figured this was the best day for a couple of reasons, first of all I get along pretty well with the residents taking call that night, and second of all that means I can go home Saturday as soon as morning rounds are over.

They tend to let us do more during surgery. Students don't do anything major, but they'll let us do more routine stuff that takes only a little practice. I can put in a Foley catheter pretty easily now - and if anyone wants a demonstration or would like to volunteer for practice, just let me know, I can do it rather painlessly (of course, it helps if the subject is unconscious under general endotracheal anesthesia).

Anyway, by 6:30 pm or so, most of the Orthopaedics residents are gone, so the call team is around to take care of any patients on the floors and to answer any pages by the Emergency Department. One thing I've noticed so far is that of the 16 beds or so in the Surgical Intensive Care Unit (SICU), almost half are filled with Ortho patients. I suppose it only makes sense that these most of these people have "MVC" next to their names, "MVC" being short for "Motor Vehicle Collision." It's astounding how many of these patients are on the service; it's almost like there's an epidemic of crappy drivers out there. Oh, waitaminute, this is Boston. Never mind.

Back to Call night. Things start off pretty slowly, only a couple Ortho consults here and there until midnight. We see a woman with a broken radius because she blocked a kick from her mad boyfriend. We see a young boy with a broken pinky because he threw a punch at - and connected with - another kid's face. Other than helping the team put on some casts, I'm able to spend most of my time doing my surgery reading. That lasts until about midnight, when I run out of steam - at that point I'm reading words, but they have no meaning, so I just lie back and close my eyes. Then the team gets hit - hard. Consults come in - not all at once, thank goodness, but steadily and without pause.

So far, the patients fall into one of three categories: Pure Accident, Fracture due to Co-Morbidity, and Human Stupidity. Pure accidents include a young man with a ruptured Achilles tendon - occurred when he was playing basketball in the gym, he jumped and landed and there it went. Pure accident. Bad news. Good news is that I'll probably get to watch the surgery in a couple days. Another 'Accidental' is a young man who broke his thumb playing soccer. The distal joint of the proximal phalanx of his thumb has been crushed into the rest of the bone. The Orthopods have to pull it out. They numb the finger with a digital block, but this is only so effective in the thumb. Ooooo, just watching them pull this joint into alignment hurts. Poor kid.

Then we see some people who have broken bones because of other diseases. These would include cancer patients who present with metastases in their bone, or elderly patients with osteoporosis. The frustrating cases are the 'Stupidity' ones - car accidents, violence, or other stupid human events. I think it's these cases that drive the Ortho intern absolutely crazy. This poor guy is the most jaded doctor I've met during third year. He's close to quitting altogether. Merely walking down the hall seems to piss him off. He asks me why I want to go into Medicine, and I mention that I like the patients. "I used to love my patients during third year. Now I f$#@ing hate them." I'm scared I might end up like him.

Around 4AM I'm starting to feel the effects of having no sleep. I'm definitely a newbie at this, and the residents are amused. "You'll get the hang of it," they say. I hope so...I think. Not only am I feeling exhausted, but I'm starting to feel pretty grimy. I wonder what I'm going to do first when I get home - shower or hit the sack. Angry Intern recommends showering. "Always shower when you get home - you have to wash off the MRSA." Ooh, gross. Now I feel even more grimy. Things get hectic about now - we have to finish with the patients on your consult list, round on a set of patients in the other hospital across campus, then be ready to round with the weekend Ortho team back at the home office. Activity tends to wake me up, and I'm Johnny-on-the Spot with the bandages and medical tape when the team needs to change dressings. When we get back to the office to round I sit down, and that pretty much puts an end to my functionality for the night.

The team sends me home around 9:30 Saturday morning. I'm groggy, but feel okay to drive home. I shower, then sleep until late afternoon. Yup, my Saturday is pretty much wasted.

Like a Surgeon. Not!

Hi,

Hank here. Well, Mike's a little out of it. He wanted a little bit of a breather. Instead, he got to start his surgery clerkship. I woke up early with him just to see how he'd do on his first day, and it was worth it. (Penguins don't usually have to wake up with the sun - we can wake up whenever, hit the beach, eat some fish, then go back to sleep again. Other than that, waking up at 3:00 in the morning - really - it's just not right). During orientation, Mikey was given a name to contact so he could figure out where he needed to be on his first day. The contact, a PGY3 orthopedic surgery resident, never called back (this happens a lot to Mikey), so Mikey had no idea where to go, only that he had to show up somewhere by 4:45 AM. He did better. He got to the clinic at 4:30 in the morning, and waited around for an hour and a half before a resident came by and then informed him that they moved rounds to 6AM that morning. Unfazed, Mikey didn't let shed any tears over the 90 minutes of sleep that he lost. Not on the outside, anyway.

The orthopedics residents are great. Always trying to get Mikey to see the most interesting things. So they threw him into a pair of scrubs and he was in the operating room - the "OR" - by 7:30 that morning. Mikey has to pray in front of this rectangular-shaped altar for his scrubs. Then he hits one of four buttons, all of which have had their labels scraped off over the years. Presumably, each button corresponds to one of four sizes - S, M, L, and XL. Mikey closed his eyes and hit one of the buttons and the Scrub Dispenser started to spin. Where it stops, Nobody Knows! I pray to the Great Penguin God in the Sky that the dispenser spits out small scrubs at the guy. Alas, he guessed right. Normal-sized scrubs. I guess Mikey's luck is taking a turn for the better.

Mikey scrubs in for the next case, an internal fixation of a fractured fibula. He scrubs in and manages to not break sterility. One of the keys to maintaining sterility is making sure that one's hands never leave the region of this imaginary box extending from the shoulders down to the waist. Basically, one's arms are flexed for the duration of the operation, an especially exhausting position if your a medical student and you're just watching the entire time. Mikey was rewarded for his efforts by being allowed to help put the patient's lower leg in a cast. Basically, all he had to do was hold the patient's leg up while the orthopedist applied bandages and plaster in what seemed like super-slow motion. Of course, this would have been much easier had his arms not been sore from maintaining the sterile position (I love how that sounds) and the fact that the patient had a BMI of like 60. I think Mikey dropped about 3 liters of sweat holding that leg up. "You doing okay there?" the orthopedics resident asked. "No problem!" Mike wheezed.

The next patient was more complex. This patient had contractures in his feet, bunions on both great toes, a heel that needed a calcaneal ostectomy, and an Achilles tendon that needed to be lengthened. This operation lasted over three hours. During that time, Mikey wished that:

1. He'd worn more comfortable shoes, and
   
2. That he had eaten something that day.

The stories of medical students fainting in operating rooms are many. It's usually not due to the sight of cadavers or blood - these people made it through Gross Anatomy already. No, it's because they're usually not smart enough to eat before scrubbing in. At about 2pm, Mikey had been in the OR for almost 6 hours, he still hadn't eaten anything all day, trying to make it through on 3 hours of sleep. Then I saw it. His eyes started to blink uncontrollably. His head started to bob as he tried to keep from sleeping while standing. I quickly made bets with the Anesthesiology crew that Mikey was going to crash face first into the operating table, thoroughly contaminating the sterile field. Several minutes later, his body started to lean backward, and - ohh!! He caught himself from falling. Dammit! Weebles wobble but they don't fall down! Sadly, I handed the anesthesiologist the ten dollars he won from me. Jerk - it's not like he needs it.¹

The rest of the operation went by without further entertainment. Mikey managed to cut a few sutures without stabbing anyone, but that's about it. He finally went home around 8 pm, a nice 16-hour day, ready to do it all again. Except next time without the penguin. I'm sleeping in.


¹ Some of this narrative is fictional and/or exaggerated. Like the part about praying to the Scrub Dispenser. And also the bit about the Hank making bets with the anesthesiologist. Okay, the fibular fracture patient did not have a BMI of 60. It was more like 50 - point being, the poor fibula just couldn't take it anymore.

The Grind

Four clerkships down, two to go. I start the Surgery clerkship tomorrow, and I have to confess that I'm starting to feel worn down. I'm still enjoying third year overall, but exhaustion is starting to seep through my entire being, and that's starting to affect my outlook on things.

I think what's kept me going so far is that I've really enjoyed my experiences in the last couple clerkships - the patient population was fantastic, my fellow medical students have been awesome, and the faculty have been very good for the most part. However, I'm now going to end third year with two clerkships notoriously known for having faculty and residents with malignant attitudes. And I'm going into these clerkships feeling mentally drained already. I don't know how I'm going to come out on the other side this time.

Part of this exhausting process is the constant evaluation going on. When you're in the clinic, you're always being watched - how you interact with your patients, the organization of your presentations, the quality of your progress notes, the breadth and depth of your knowledge. When you're not in the clinic, you need to be reading your ass off in the hopes that it's somehow going to get you through the end-of-the-clerkship exam. Let's get this out of the way: I am a really crappy exam taker. I get by okay, but I'm not knocking anyone's socks off. Which is fine because it's our clinical evaluations that carry more weight, and I'm doing very well with those. But these shelf exams that we take at the end are absolutely brutal - 100 questions in 2 hours and 10 minutes. That's one minute and 18 seconds for each question and you really need to complete these exams at a blistering pace. A minority of these questions are of the type that you read and know the answer right away. Most of them require reading of a medium-length paragraph with some lab values in a table afterwards. One can usually eliminate a couple choices right off the bat. Think a little harder, and you then get it down to the best of two choices. Me, I tend to agonize for way too long over those last two choices and I end up scrambling to finish at the end. This is the closest I've ever come to panic attack. When it's all over, I feel like someone's taken a blade to my stomach and spilled my guts all over the floor. I go into these things with absolutely no confidence and have to seriously consider getting prescription beta-blockers for these exams. I just don't feel like I have the energy to make it through this anymore.

My confidence after these things is so shattered that I end up extrapolating this experience into everything else going on - making me feel like I've hit my upper limit, as far as medicine goes. And I haven't even gone into the process of applying for residencies at this point. But I hold on to that little glimmer of hope somewhere - it's in here somewhere, I think - that if I can just finish this year then things will be okay. I just don't know where I'm going to get that second wind from. I need to recharge - quickly - and I don't know how.