not yet dead

an actual consult for neurology while I was on the service:

phonecall directly from the operating room (OR):

Surgeon: My patient can't move his hand.  I think he had a stroke.  Do I call you guys for a consult?  Do I call the ED?
Neuro Resident: You call us, that's fine.  What happened?
Surgeon: Well I gave him a brachial plexus block and operated on his hand, but now the surgery's over and he can't move his hand.
Patient: (in the background of the call, really loudly)  I'm fine. I can move my hand!  Just untie me and I'll be fine!
Surgeon: oh.   I guess he's okay.
Neuro Resident: so you don't want that consult then?
Surgeon: yeah, probably not.  (hand up awkwardly)

We laughed so hard (though obviously, really good for the surgeon to call if he thought his patient was having a stroke) - but I just couldn't get Monty Python out of my head:

10 things I learned in surgery

1. the enemy of good is better (otherwise known as, doing more isn't always the right move)
2. the art of being a surgeon is first knowing when NOT to do surgery
3. when asked a question that you don't know the answer to, first: say you don't know, then say what you do know (as in, we don't know if she's going to recover fully but we do know that her kidney function has returned to normal more quickly than we would have expected).
4.  the surgeon is the head of the team, act like it. thank your team for what they do, and most importantly, tell your team what's going on so they can do their jobs the best they can.
5. how you do one thing is how you do everything, so make sure your values are reflected in all you do.
6. from one of my vascular attendings to a diabetic man who had already had one below-the-knee amputation due to low blood flow from his arteries not working well due to his extensive smoking behavior and diabetes "hey man, you're smoking your leg off" - (aka surgery isn't always the end of a problem).
7. bad news should always be hard to deliver, no matter how much experience you have.
8. the major causes of fever after surgery all start with W:
1) wind (atelectasis, pulmonary embolism), 2) water (UTIs), 3) walking (DVTs), 4) wound (infections), 5) wires (foleys, NG tubes, J tubes, ventilators), 6) wonder drugs (lots of drugs can cause fever)
9. a pulse is more important than breathing.  CPR guidelines just changed to focus on pulse first, then airway, then breathing.  so #1: feel for a pulse, if it's not there, start chest compressions
10. set yourself up for success - in surgery, 90% of the success of the surgery is deciding the approach.  If you don't feel comfortable - adjust something.

You just stop stopping it

When asked how you restart the heart after stopping it temporarily to put it on bypass, the perfusionist said to me:  "It's zen-like, really, you just stop stopping it"

Thursday around noon I scrubbed into my first Cardio case - a CABG (coronary artery bypass graft) surgery on a 74 year old woman who we'll call Elizabeth.  The procedure is done by taking a blood vessel from somewhere else in the body (in this case, the saphenous vein in the leg), disconnecting it from its normal place and reconnecting it to the heart to bypass a clogged coronary artery (artery that supplies your heart).  It's a pretty awesome procedure, but it's also done often enough that the expectations when you have one is that you'll be in the hospital for 4-5 days then go home and have to take it easy for a while during which time you feel so much better because your heart is working well again.

Needless to say, if that was the way this surgery went, I probably wouldn't need to blog about it.  I wrote a five page journal entry of everything that happened and my reactions to it, but I'll spare you most of that and just tell you what I'm still thinking about a few days later.

The surgery started out fine and routine, certainly not light-hearted, but pleasant.  Then slowly but surely everything started to go wrong; we couldn't keep her blood pressure high enough to adequately perfuse her organs, we couldn't get the wound on her leg from where we took the vein graft to stop bleeding, her right ventricle wasn't moving enough to pump blood through to her lungs, her skin was too thin to put stitches in to keep her chest closed.

20 hours and two additional surgeries later, she was left with an open chest where her heart had been attached to an external pump called an LVAD that was pumping blood around her right heart to give it a rest, a ventilator on her face attached to oxygen to make her lungs breathe, a line in her jugular vein, in her femoral artery, in both her antecubital fossas (inner elbows), her legs were stitched together along the whole middle side, like the seam of pants except her skin, she was bruised and swollen from the poking and the fluid and blood we had given her to try to keep blood flowing to all of her organs.

I went home at 4am, exhausted, wondering if she would make it through the night.  The next day I was in the operating room with a bariatric surgeon from 7am until I got a break at 3pm, so as soon as I got out of the OR I went to check on Elizabeth.  She was in the cardiac intensive care unit in the same state but even more bloated and with even more wires connected to her.

The surgeon was just coming by to talk to her family again and invited me to come to that discussion, so I went with him and heard Elizabeth's two sons and their two wives (who happened to be sisters, oh Maine) tell the surgeon that their mother would never have wanted to live like this.  Before deciding to have the surgery, she had decided her code status would be "Do Not Resuscitate" specifically to avoid this situation.  However, the surgeon did not want to accept that they would stop trying and just kept repeating, "we've done almost everything, but there are still a few things we can try; her left ventricle looks great; it's not likely but there's a small chance she will recover in some way; I can't say definitely that she won't have at least some turnaround"


I wanted to scream at him: they're saying that's not good enough - that some turnaround or a small chance that she will recover in some way is not enough of a reason to put her through this suffering.  They're saying they are ready to stop all this intervention.  But he kept pushing it: we can give her more blood, we can run some more tests, we could maybe do another surgery.  To Elizabeth's family's credit, they cried and lamented but they were clear - she would not want this.

When talking about it with another one of my attending from the trauma surgery service later that day, he described this behavior of surgeons: when they don't seem like they are listening and they just want to keep pushing even though it's time to stop, as Tunnel Vision.  He said, and you want them to have tunnel vision sometimes because it takes such focus to take a vein out of your leg and sew it to your heart and have you walk out of the hospital a few days later able to breathe and move again.  But this same focus sometimes makes it hard to see the person as a whole person, as a whole life, instead of just the organ they're working on.  This attending and I also talked about how to have conversations with families where you give them information that their family member is dying - how it should be straightforward, as objective as possible, laying out the options as clearly as possible, and how you should mostly be listening.  The biggest thing, he said, is that it never gets easy - even when you've done it thousands of times, it's always hard to tell someone that someone they love is dying.  And it should be.

getting stuck

today I was first assist on a below-the-knee amputation on an older man with diabetes.  It's a pretty brutal operation - as in, they actually use an actual bone saw, a very large knife and it's less possible than I thought it would be to precisely cut off the muscle in someone's leg.
But somehow I do have the stomach for surgery -  so even though at moments it seemed like a halloween trick gone awry,  I was able to focus on how fascinating it was to identify and technically interesting it was to  isolate the three major neurovascular bundles in the leg (sort of like tubes containing nerves and the blood vessels that supply them).

the attending sutured the muscle/fascia layer because that is the critical layer for holding the operation together

but then he let me suture half of the skin line.

I've just started feeling more confident in my suturing and yesterday I got to suture a lot, 

so I was feeling almost confident

until I stuck my own finger with the needle.

this is not an uncommon thing in medicine
in fact, the first thing that happened was that the scrub tech, the circulating nurse, and my attending all empathized with me and told me how many times they had been stuck

then they told me to take off my gloves and gown and go wash my hand with bleach
I was escorted from the OR to another building in the hospital to start the "needle stick protocol".
this consisted of me walking into the employee health center and being immediately ushered into a small room (they were expecting me because the OR had already called them), filling out a report about what happened, hearing what would happen from there on out:



1. The patient would be told that one of the health care workers in his surgery had been exposed to his blood, would he consent to be tested for HIV, HepC, and HepB please?  (he said yes) Would he please fill out a survey outlining his risk factors? (his wife did, he was still waking up from anesthesia)
2. I would fill out these incident reports.  One would be filed with employee health and one I would take to my supervisor.  Because I'm a med student and don't have a medical health record number, I would also have to create one of those.
3. I would have to have five tubes of blood drawn from the lab downstairs, now.
4. the nurse on call tonight would call me back with the results of the patient's STAT HIV test.
5. they would call me tomorrow with the results of his other tests and by Monday with the results of my tests
6. if I had any questions, I could call them.  If the tests were negative there was nothing else to do. If they were positive - well, there are more tests.
So I did.

I am really really lucky.
Less than two hours later, they called me with his previous lab results (all negative), and his risk factors ( blood transfusions in the hospital only - very unlikely to contain HepC or HIV), and later this afternoon called me with the results of his STAT HIV test - negative.
The nurse on the phone told me that I could breathe a big sigh of relief -
but that she'd still call me with all the rest of the test results.

Talking on the phone with the manfriend, he sounded almost more worried than I was, realizing for the first time that if we are both going to be doctors we are going to be at greater risk of contracting some pretty serious diseases.  And maybe more importantly, how will we organize our careers around this - will we try not treat people with more easily contractable incurable illnesses like HIV/AIDS? (hopefully we will treat them just the same as anyone else)  Will we wear more layers of gloves?  Will we be better about getting vaccines?  Get serum tests for transmissible diseases every year?  Or maybe just try hard not to think about it too much and carry on with what we've decided are our respective callings?

This article caught my eye because it explains some of the very scary things that can happen to med students, and yet is still very inspiring.  I'm reading Abraham Verghese's In My Own Country right now, which is about his own experience treating the first patients with HIV and it's making me think a lot about the balance between protecting yourself and providing good medical care.

~~~~~~~~~~~~~~~~~~~
"But we also agreed that what made the difference in life was not how well you succeeded;  it was how well you failed, how many times you picked yourself up
and put yourself back in the fray."
- Dr. Dietrich 
who contracted HepC from a needle stick as a third year medical student, 
see the article above

Surgery at the End of Life

I've been thinking a lot this week about how strange it is that so many people are choosing such serious interventions for medical problems that are likely to not be their cause of death.  Don't get me wrong, we can do really amazing things with surgery and interventions now that save lots of lives and maybe even more importantly, improve the quality of life for so many people.  But it still seems like mostly, surgery should be an option of last resort.  Maybe this is more striking because I'm seeing all the patients in the ICU and in the hospital after surgery and recovery can be such a brutal process that it seems like, especially at an older age, surgery would be something you would want to avoid unless it was going to really make a difference in either the quality or quantity (or both) of years in your life.
Sometimes I wonder how much of it is just us not wanting to NOT be able to do something.  Like I said at the beginning of this surgery rotation, the really good surgeons are the ones who know when NOT to operate.

Check out this interesting article in the Times about how common surgery is at the end of life.

Dr. Jha provided a recent example from his hospital. A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine. “No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.” Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.

The man died of a complication from the surgery.

“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea." Instead, Dr. Jha said, “we sent him to the O.R.”

Coaching

last night I was on call and around 4pm, a young guy came in with a gunshot wound to the knee.  Before I knew it, I was four hours into my first vascular surgery with the young guy on the table, both legs sliced open on the medial (inside) side).  The two surgeons I was working with were using a vein from one leg to take the place of the severed artery on the other leg, called "grafting" an artery for a bypass.  

I learned many things last night about vascular surgery and about vascular surgeons.  In their own words, these attendings said that vascular surgeons have to have the biggest egos, secondary only to cardio-thoracic surgeons (the men and women who operate on hearts and lungs).  They also are perfectionists - and need to be.  So I was surprised when near the end of the case around midnight, I was handed 0 nylon on a needle driver and forceps (big tweezer-like things that surgeons use to pick up skin to suture; suture = to put in stitches) and told to stitch up one of the groin incisions.  But I did.  The entire time, one of the attendings asked me questions about the physiology of the vascular system (for example, "what would I feel if I had accidentally attached this vein graft to the popliteal vein instead of the popliteal artery?"**)  while the other coached me on better technique for suturing.  Both of them were incredibly focused on details (appropriately for their profession) which is not typically my strength.  However, paying more attention to the details (where  your shoulders are facing, how far onto the needle driver you arrange the needle, locating each layer of fascia before creating a fasciotomy) ended up making such a huge difference.  

They say in surgery, if it feels like you're struggling to do something, you need to change something - because the best surgery is when everything is in line.  The change can be something as easy as switching the angle of your wrist or walking to the other side of the table or adjusting the light.  There are millions of things we can adjust but sometimes we think that they're just details.  But surgery has definitely taught me that the details truly matter.  Especially when learning, it's so important to learn the details before getting a gestalt.

On that same note, a few great friends sent me an article from the NewYorker by Atul Gawande, another one of my favorite doctor-writers: Atul Gawande, who writes about  how after their training is complete, surgeons (and maybe all doctors, maybe all professionals) operate without much supervision, without much continued assessment, and miss out on much improvement simply because no one is watching them and coaching them on how they can be better.  He relates this to professional athletes - who even though they are deemed the top of their fields, have other people who watch them as they cannot watch themselves, and help them improve.

Dr. Gawande also talks a lot about teaching styles and coaching teachers, another profession that is trained and then sent off into the world to manage on their own.

A great excerpt:

"Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence to conscious competence and finally to unconscious competence. The coach provides the outside eyes and ears, and makes you aware of where you’re falling short. This is tricky. Human beings resist exposure and critique; our brains are well defended. So coaches use a variety of approaches—showing what other, respected colleagues do, for instance, or reviewing videos of the subject’s performance. The most common, however, is just conversation."

In the vascular surgery last night, it took so much of my brain power to both answer the questions and try to suture correctly that I don't think I even breathed the whole time, but afterward I felt like I had a greater understanding of what I need to learn to be a better doctor, moving more comfortably into "conscious incompetence".

**answer: no pulse because pulse is created by the resistance in arteries - and veins don't have very much resistance.  You would feel a thrill, which is a whooshing of blood past really quickly, instead.  If you listened to the graft, you would hear bruits, which is the sound of blood going by very quickly.

on call pocket

I dumped out my pockets in the middle of my call today to change scrubs and was shocked at all the things that came out.  so I took this picture.

the contents of my pockets today include:

- 1 surgery book

- 2 pagers (trauma pager and my pager)

- glasses

- pen

- stethescope
- watch (bc you can't have it on when you scrub)

- gum (gotta have fresh breath in the OR)

- extra gloves (just in case)

- sutures (to practice in between surgeries)

- spare change (for breakfast, coffee, lunch...)
- splenda (also just in case?)
at some point I also had a coffee mug but I put that down somewhere.

kinda crazy, right?

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"may your pockets be heavy, may your heart be light
may good luck pursue you each morning and night"
-an irish blessing

The Mind of a Surgeon

(and yup, that ones actually me - in my lead suit to protect me from x-rays! - can you tell I'm smiling?) 

today in the OR I was talking with the PA who was first assisting about the Whipple procedure we (really she and the attending) were working on.  A Whipple is a procedure most often done for pancreatic cancer, but because the pancreas is sort of hidden within all the folds of the intestines it's often hard to see on imaging and therefore hard to figure out if there is a tumor there.  This means that in the beginning-middle of the procedure, the surgeon takes biopsies of the pancreas and sends them to the lab to be quickly assessed by a pathologist.  This usually takes anywhere from 10-20 minutes and then the pathologist calls the OR and tells the surgeon: cancer or not cancer (and a few more details).  This pathology report along with the surgeon's own view of that patient's abdomen (to see how far the cancer has spread, if there is any) determine if the operation will continue.  

so anyways, while the surgeon was on the phone talking with the pathologist, I asked the PA what we would do differently if the biopsy came back negative for cancer. Our suspicion of cancer was high in this particular patient and I was really wondering if we would a) do more biopsies to see if we just missed the cancer, b) proceed with the operation anyways because we were pretty sure he had cancer and NOT treating pancreatic cancer has a <1year survival prognosis, or c) wait and not do the procedure because of the risks.  

she said she didn't know.  That even though she knew the technique of the procedure and had done it many times, she had no clue about the clinical decision-making involved and didn't seem very curious about it.  So I asked the surgeon who explained the intricacies of how we decide what to do - and how sometimes it's each of the decisions above, depending on the patient and the cancer.  Which is when I realized, that's why I went to medical school (and not PA or NP school, which I also considered) - because I want to know all the WHY we do things in medicine - not just the HOW.  To clarify, I'm not saying that all PAs do not care about the WHYs; actually there's a lot of the WHY involved in really knowing the HOW.  But it was affirming for me because when people ask me why I went to med school - and not PA or NP programs - I tell them that I wanted to be calling the shots.  Not all of them, and not always by myself, but I wanted to strive to be able to practice medicine in line with my own clinical knowledge and decision-making.  So it's cool to realize that this clinical decision making is what makes doctor training different and that I am being taught how to do it.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"When it's over I want to say: all of my life I was a bride married to amazement, 
a bridgegroom taking the world into my arms"

- Mary Oliver (one of my most favorite poets)

Welcome to the Monkey House

Day 1 of Surgery 

I'm introduced to my first preceptor, a surgical oncologist who we'll call Ted.  Ted spent most of his life in Texas (and has a thick southern drawl to prove it) before he became a surgical chief and a Colonel in the Marine Corps for many years before going into private practice.  So the first thing I have to figure out is do I call him Doctor or Colonel or both.

Within minutes of meeting him we scrub into a breast cancer surgery.  My second day, we start with tumor board, which is a pretty awesome concept actually.  It's when the group of physicians and staff who treat cancer get together to talk about particularly difficult cases.  The surgical oncologists, the medical oncologists, the pathologists, the radiologists, and if appropriate, the residents and medical students are all in attendance.  We go through each case thoroughly, with the primary doctor presenting the case, then the radiologist showing what was found on imaging, and the pathologist showing what was found in the specimen, and then everyone chimes in with their two cents.  I think it's one of the fine times in medicine where there is true collaboration.  

After tumor boards, Doctor Colonel says to me:  "I'm gonna tell you the best piece of advice given to me by an attending.  He said, son, we could teach monkeys how to do surgery.  Hell, we could teach really smart monkeys to decide when to do surgery.  But why we're special is because we can decide when not to do surgery".  

(ps: as you've probably noticed, that's not really a photo of me, I've already asked and apparently I'm not allowed to take any photos in the OR)

~~~~~~~~~~~~~

"I urge you to please notice when you are happy, and exclaim or murmur or think at some point, 'If this isn't nice, I don't know what is'"

-Kurt Vonnegut

Where are all the grown-ups?

Today I had two surgeries (by "I had" I mean I generally watched and held things): one was a dramatic robotic surgery that was more difficult than they thought it would be so they converted to an open surgery. The second surgery was a suction evacuation of a woman who had had a failed termination of a 9 week pregnancy 3 weeks before and subsequently developed an infection along with not actually terminating the pregnancy. It was one of the most interesting cases I've had yet, not because of the procedure but because of all the ethics and emotion tied up in the case. For starters, it was hard to find staff for the case. It ended up being one attending who did not want it known that she performed terminations and two residents (A first year and a second year) along with a first year anesthesia attending and a circulating nurse who was about my age.

I definitely had a thought before we started like, "but where are all the grown-ups that are usually in the OR with us?" but everything went really well and obviously the OB attending was there, mostly teaching me and confirming what the residents were doing/finding.

After the procedure, we have to confirm that the "products of conception" have been removed from the uterus. This involves piecing through the specimen to find evidence of a gestational sac and organs/structures. It felt very strange but oddly similar to my undergraduate research lab to be searching through bloody mush to find specific parts.

I ended up sitting with the patient a long time afterward because she was so emotional and so scared. It was the one moment this rotation that I've been glad to be a medical student - because I didn't have to run off anywhere to do all sorts of other things and could just answer all her questions whenever she had them. (because otherwise, it's been infuriating to be a medical student and mostly observing...)

Ob-gyn is still going well - I'm done with q2 (every other day) 24 hour shifts on OB and have moved on to the "gyn" section which is a lot of surgery and outpatient clinics, but still requires me to be at the hospital before 5am. A few days ago I had a complete scraping-the-bottom-of-my-barrel-of-energy day where everything felt overwhelming and I felt incompetent. Then I remembered that the last time I got more than 5 hours of sleep at one time was about 3 weeks ago and that I still don't know what meal my body feels like it should be eating. After a run, a good dinner, a glass of wine, and an early bed time (6hours last night, hooray!)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

"self preservation is a full time occupation"

-ani defranco

intubation

this past week I had a "bridge week" between clerkships where we learned all about

Anesthesiology.

which really means 5 big things:

*I went into an OR during a surgery for THE FIRST TIME.

(I know what you're thinking, your FIRST time in an OR? how long have I been in medical school? but yup... I also felt the need to announce that it was my "very first time in an operating room" to the entire room - which got me some strange looks, but maybe a little extra help too ??)

*I learned what an anesthesiologist actually does (and how much fun anesthesiologists are)

*I placed IVs, then let people practice placing them on me

(actually totally painless thanks to a lidocaine injection and excellent technique from my fellow medical students :) )

*then I INTUBATED TWO PEOPLE -

which, for anyone who isn't quite sure what that means, kind of looked like this video from the TV show ER except a whole lot less dramatic.

*we talked a whole lot about management and leadership, and about doctors as leaders. These discussions were probably the coolest part. The difference between management and leadership is that Management helps maintain a system and Leadership is how you change a system.

Doctors need to be a part of both.

For the final day, we read an article about how to evaluate your life in the HBS Review. The author says in order to make sure your energy and time go to the right things, ask yourself 3 questions (paraphrased):

(1) how will my career make me happy and fulfilled?

(2) how will my significant other and my family be a continuous source of happiness and growth?

(3) how will I stay out of jail?

He says the third question seems like a joke, but one of his classmates was Jeff Skilling, the infamous CEO of Enron, so maybe not...

~~~~~~~~~~~~~~~~~~~~~~~~~~

"the first responsibility of a leader is to define reality,

the last is to say thank you"

-max depree