The Core, Day 1
Two electives (orthopedics, surgical oncology) into my surgery clerkship, and I think that I might like surgery. At the very least, I don't hate it. That is, until the first day of my core general surgery clerkship. Student responsibilities were the following:
"It's just a simple ventral hernia repair," they said. Okay, I'm game. The operation is to be performed via laparoscopy, meaning smaller incisions, a fiberoptic scope, long instruments, and a couple of television towers to visualize what's going on. It's a little like a video game.
I scrub in and stand at the foot of the operating table as the surgeons begin. The abdomen is insufflated, and what I see is amazing. Normally, the abdominal wall forms a yellowish-white dome streaked with dark red branching arteries. The floor of the dome is comprised of the organs - stomach, liver, and intestines. Neat and orderly. It's like an anatomical BioDome.
What we see instead is something out of a brochure for a cavern tour:
The patient's guts are tethered to the abdominal wall. What could have been a two- or three-hour operation has become more complex. And I have to just stand there and watch it. Mind you, there's no way that I should be doing anything in an operation like this. Put these instruments into a students' hands is asking for trouble, say, lacerating the liver or nicking the gallbladder or perforating the bowels. No, not a good decision - all of a sudden the laparoscopic procedure becomes an open procedure and lengthens the duration of the operation. Anyway, the surgeons have to carefully cut the adhesions, releasing the abdominal contents down the floor where they should be, avoiding injury to the organs or to any major arteries. They do this very meticulously, meaning it TAKES HOURS.
1300: I get called to the OR, because the operation is supposedly starting early. I don't scrub in until an hour later.
1400: The operation actually starts. Two attendings, an intern, the scrub nurse, and a medical student are standing around the table, with two anesthesiologists, and the circulating nurse, a large galoof of a man. Let's get this party started.
1500: The surgeons make a comment that this operation is going to suck. I have no idea what this means at the time. The intern that is handling the laparoscope is booted politely from his duties, as they need a more experienced person to handle the camera. They call in one of the Surgery Chief Residents.
1600: They release a stretch of bowel from the abdominal wall. No bleeders. Good.
1630: I realize that I haven't eaten anything since this morning. The nice thing about being dehydrated is that you don't have to go to the bathroom. The average adult, with healthy kidneys, should make about 40 milliliters of urine per hour. I'm probably making about 10 right about now. There are very few acceptable excuses for a medical student to break scrub. Having to go to the bathroom is certainly not one of them. Heck, either is having to go to lecture. The only way to get out of the OR before it's over is to make some egregious mistake and enrage the surgeon enough so he kicks the student out.
1700: The Chief Resident lays the camera down momentarily to perform some other maneuvers. It almost slips off the patient before I grab it and prevent it from falling to the ground. "That kid is THE MAN!" one attending notes. I'd swell with pride, but I think I'm too dehydrated to do so.
1800: A bunch of pagers go off at the same time. The circulating nurse has trouble sorting out which ones these were, so I helpfully point out a few sitting on an isolated table in the corner. He ignores me. Humph. The chief resident has to scrub out - it's his anniversary, after all, and he has to get out of there. Lucky bastard. They call in another senior resident to take over his duties.
1825: Every muscle required for posture is now screaming. Only now do I realize how difficult it is to stand still in one spot for such a long time. I lean on the scrub nurse's tray. That's okay, until I place my foot on the base, accidentally hitting the release so the tray comes crashing down onto the patient's legs. Whoops. "Kick that kid outta here!" the attending jests. Argh. Any cred I'd earned by saving the scope from falling out of the sterile field is gone. And they still won't let me leave.
1900: The last stretch of bowel comes down from the wall. It's cathartic. Like a niiiiice Type 3 in the morning. The circulating nurse announces that the Red Sox-Yankees game has just started. Ah...a dedicated member of Red Sox Nation. Perhaps he would have acknowledged me had I sounded the Red Sox Nation Mating Cry: "I could handle the Red Sox pitching staff better than Terry Francona." I would have had instant credibility, I think.
1915: The attending asks for another set of instruments. The circulating nurse doesn't hear, as he's too busy checking the score of the Red-Sox/Yankees game on the OR computer. Okay, I'm officially labeling this guy's fandom as pathological. He and I don't see eye-to-eye, obviously, in that I have no desire to bear Curt Schilling's children. I silently wish Red Sox Boy to do his darn job so I can get the heck out of here.
1930: I think I'm sleeping on my feet. In my half-awake condition, I hear one of the surgeons wondering if that's blood or bile pooling inside the abdominal cavity. Nooooooooooooo!
I hear this and a shot of adrenaline courses through my veins. We are almost seven hours into this operation and if this procedure is converted to open, I will lose it. Luckily, no such complication is found.
2030: Finally, all incisions are closed and I can go home. Jeez.
If the rest of my core clerkship goes like this, I'm not going to make it.
- Get the vital signs for all the patients on the service in time for morning rounds. Morning rounds start at 0530, meaning that we need to get to the hospital by 0430 in order to grab all the numbers and pre-round on any patients that we're following.
- Make sure that a student is present and scrubbed in for every surgery.
- Be in the clinic when you're not doing #2.
- Attend the scheduled lectures. Only during these times are we excused from doing #2 or #3.
"It's just a simple ventral hernia repair," they said. Okay, I'm game. The operation is to be performed via laparoscopy, meaning smaller incisions, a fiberoptic scope, long instruments, and a couple of television towers to visualize what's going on. It's a little like a video game.
I scrub in and stand at the foot of the operating table as the surgeons begin. The abdomen is insufflated, and what I see is amazing. Normally, the abdominal wall forms a yellowish-white dome streaked with dark red branching arteries. The floor of the dome is comprised of the organs - stomach, liver, and intestines. Neat and orderly. It's like an anatomical BioDome.
What we see instead is something out of a brochure for a cavern tour:
The patient's guts are tethered to the abdominal wall. What could have been a two- or three-hour operation has become more complex. And I have to just stand there and watch it. Mind you, there's no way that I should be doing anything in an operation like this. Put these instruments into a students' hands is asking for trouble, say, lacerating the liver or nicking the gallbladder or perforating the bowels. No, not a good decision - all of a sudden the laparoscopic procedure becomes an open procedure and lengthens the duration of the operation. Anyway, the surgeons have to carefully cut the adhesions, releasing the abdominal contents down the floor where they should be, avoiding injury to the organs or to any major arteries. They do this very meticulously, meaning it TAKES HOURS.
1300: I get called to the OR, because the operation is supposedly starting early. I don't scrub in until an hour later.
1400: The operation actually starts. Two attendings, an intern, the scrub nurse, and a medical student are standing around the table, with two anesthesiologists, and the circulating nurse, a large galoof of a man. Let's get this party started.
1500: The surgeons make a comment that this operation is going to suck. I have no idea what this means at the time. The intern that is handling the laparoscope is booted politely from his duties, as they need a more experienced person to handle the camera. They call in one of the Surgery Chief Residents.
1600: They release a stretch of bowel from the abdominal wall. No bleeders. Good.
1630: I realize that I haven't eaten anything since this morning. The nice thing about being dehydrated is that you don't have to go to the bathroom. The average adult, with healthy kidneys, should make about 40 milliliters of urine per hour. I'm probably making about 10 right about now. There are very few acceptable excuses for a medical student to break scrub. Having to go to the bathroom is certainly not one of them. Heck, either is having to go to lecture. The only way to get out of the OR before it's over is to make some egregious mistake and enrage the surgeon enough so he kicks the student out.
1700: The Chief Resident lays the camera down momentarily to perform some other maneuvers. It almost slips off the patient before I grab it and prevent it from falling to the ground. "That kid is THE MAN!" one attending notes. I'd swell with pride, but I think I'm too dehydrated to do so.
1800: A bunch of pagers go off at the same time. The circulating nurse has trouble sorting out which ones these were, so I helpfully point out a few sitting on an isolated table in the corner. He ignores me. Humph. The chief resident has to scrub out - it's his anniversary, after all, and he has to get out of there. Lucky bastard. They call in another senior resident to take over his duties.
1825: Every muscle required for posture is now screaming. Only now do I realize how difficult it is to stand still in one spot for such a long time. I lean on the scrub nurse's tray. That's okay, until I place my foot on the base, accidentally hitting the release so the tray comes crashing down onto the patient's legs. Whoops. "Kick that kid outta here!" the attending jests. Argh. Any cred I'd earned by saving the scope from falling out of the sterile field is gone. And they still won't let me leave.
1900: The last stretch of bowel comes down from the wall. It's cathartic. Like a niiiiice Type 3 in the morning. The circulating nurse announces that the Red Sox-Yankees game has just started. Ah...a dedicated member of Red Sox Nation. Perhaps he would have acknowledged me had I sounded the Red Sox Nation Mating Cry: "I could handle the Red Sox pitching staff better than Terry Francona." I would have had instant credibility, I think.
1915: The attending asks for another set of instruments. The circulating nurse doesn't hear, as he's too busy checking the score of the Red-Sox/Yankees game on the OR computer. Okay, I'm officially labeling this guy's fandom as pathological. He and I don't see eye-to-eye, obviously, in that I have no desire to bear Curt Schilling's children. I silently wish Red Sox Boy to do his darn job so I can get the heck out of here.
1930: I think I'm sleeping on my feet. In my half-awake condition, I hear one of the surgeons wondering if that's blood or bile pooling inside the abdominal cavity. Nooooooooooooo!
I hear this and a shot of adrenaline courses through my veins. We are almost seven hours into this operation and if this procedure is converted to open, I will lose it. Luckily, no such complication is found.
2030: Finally, all incisions are closed and I can go home. Jeez.
If the rest of my core clerkship goes like this, I'm not going to make it.
posted by Mikey at 6:54 PM
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