Archive for September, 2009

Like a Moth to Flame

September 18, 2009

The last three weeks of my surgery rotation (on the trauma/emergency surgery service) have been by turns mind-blowing and terribly sad, exhausting and exhilarating.

I think that the range of those emotions are well summarized on one of my call days about a week ago.

Trauma call starts when you get to the hospital (~5am) and ends when you leave the next day after rounds and conferences (~10 or 11am). As a result, you spend about 30 consecutive hours in the hospital. While on call, your team is responsible for evaluating all the trauma-related patients that come into the ER in that time, as well as the emergent surgeries that cannot wait until the next morning (appendicitis is probably the best example). Being a medical student, I am responsible for nearly nothing (cutting clothes off of injured patients and holding retractors are not exactly a highly trained skills) but it affords a front row seat to events.

Anyhow.

The day started kind of slow, but I saw that my favorite third year resident was on that night with me (he likes to get the medical students involved in working patients up, enjoys teaching us and tries to let us know when patients are headed to the OR) so I figured that boded well. Over the course of the night, I got to scrub into four separate operations; two laproscopic cholycestectomies (removal of the gall bladder with cameras and tiny little grabby hand things without making big cuts into the abdomen), a laproscopic appendectomy, and an incision and drainage of a breast abscess.

I’m not gonna lie, there is something amazing about laproscopic surgery; you are looking at this person’s insides . . . from the inside!! You poke this little camera in there, and you can pan around and see all the major organs hanging out in your abdominal cavity. And using that and some little grabby things, you can do some basic surgeries like removing the gall bladder or appendix. I wish I could better express the wonder of it all, seeing peoples insides on a TV screen that I (they let me direct the camera!!) control. And there is something very satisfying too, about seeing and examining the patient in the emergency room, ordering some quick tests, making a diagnosis (not me, but just watching the process is pretty sweet) and then forming a plan that involves literally cutting the problem out with your two hands and some tools.

That was the happy intense part of the evening. The sad intense part of the night was a teenage girl who had shot herself in the head and was rushed via helicopter to the medical center. When a trauma comes in, all we get is a page on our pager telling us the rough severity (911 is the most severe, 933 is the least) and the time until the patient’s arrival. And so what usually happens is the trauma and ER teams are hanging out in the room, all gowned up and ready to go with nothing to do, not sure if it’s gonna be some big case, or someone who just got clipped with a bullet on the tummy (because it involves bullets and abdomens, they usually get coded the same).

The girl shows up with the paramedics with her head almost entirely covered with bandages. The first task in any trauma is to cut the clothes off the patient so it’s all out of the way. While this was happening, I could see blood oozing out of her nose, mouth and ears. The doctors checked the wound in her head, and immediately blood started gushing out of one of the bullet holes. It looked like someone had taken a pen and punched a hole in the bottom of a milk carton or something, the way the blood was coming out. They continued their evaluation of her, while trying to get big IVs into her to start giving her blood and fluid. Somewhere in the middle of that, her heart stopped beating, and she was coded for about 20 minutes. I was stuck in the middle of this whirlwind, and really the only useful things I could do was help pass medications and equipment, and clear off the piles of used packaging and bandages that pile up like snowdrifts.

They were able to get her heartbeat back, and she was quickly bundled off to the CT scanner to look at the damage to her head. The images came back showing ‘non-survivable injuries.’ All the same, she was hurried back to the ER (the ‘sick’ and actually sick patients looking on from their gurneys as this little girl comes by on her bed) where they continued to give her blood and fluids. I helped the nurse and my R3 take down the dressing on her head, and pack it in an attempt to slow down the bleeding so she wouldn’t bleed out before her family and the organ donation people could get there. I don’t think I will forget the force with which my R3 was packing the wound; basically jamming bandage into the hole in her head. You could feel his frustration and anger. He packed the wound so forcefully, little bits of her brain came oozing out the sides and seeped into her pony tail. I helped wrap the rest of her head.

Her father and uncle arrived soon after, and I snuck into the small room with my R3 and the trauma chief where they were waiting with a social worker, and watched their reaction when he told them that her injuries were not survivable. Her father kept repeating that she was such a good athlete and student. It was one of the most emotionally intense moments I’ve ever experienced. She died a few hours later.

Over the course of the night, I snagged a grand total of 30 minutes or so of sleep.

I guess where I am going with all this, is that surgery is a brutal, beautiful, taxing (physically and emotionally) . . . and tempting field. Being in the operating room, and fixing someone with your bare hands and seeing them recover afterwards is a feeling hard to beat. There is a directness and a bluntness to surgery that I enjoy. Surgeons will tell it to you like it is. But on the flip side, there are a lot of surgeons who are hard-assed assholes. The hours can be insane. And it will take a long time to work my way up the seniority ladder in our 5-7 years of residency, before I am in a position to actually start acting like a real surgeon.

Kinda like a moth to surgery’s flame though, it’s appeal is hard to pass by, and I can see that making the decision to do surgery or some other path is gonna be a difficult one. They say that if you are going to choose surgery, you need to love the operating room. I think I do, but really can one actually be sure? I don’t know. I chose medical school because I thought that I would never be bored, because of the chance it afforded me to do good work and have real responsibility. I feel like surgery will do those things for me, but I balk at just how hard that path is going to be. But perhaps taking the harder road is worth it in the end. I don’t know, and I guess we will see.

And some words of wisdom from Grays Anatomy (from an episode themed, ironically, about responsibility):

“When did we become adults? And how do we make it stop?”

Wins and Losses

September 5, 2009

It’s been quite a while since my last post; internal medicine and now surgery have managed to pretty effectively swallow what life I had managed to have while on pediatrics.  But long story short, I really enjoyed myself on internal medicine, and now on surgery, I am getting a chance to see what the hype is all about.

Over the course of those rotations and especially now on surgery, I’ve come to form a theory explaining a bit of third year psychology.  In medicine, there are wins, and there are losses.  A win is when you do something good, like when a patient thanks you, you answer a pimping question correctly, someone notices/mentions your hard work, you put together a good presentation, and so on.  A loss is when you make a social faux pas (no, that’s not the intern . . .  he’s a chief resident), answer pimping questions wrong, are ignored, do something stupid, etc.

During the clerkships, there are a lot more losses than wins.  Sometimes a single win is all you need to give you the strength and the passion to bounce out of bed and zip to the hospital in good spirits for days, even if the previous days have been littered with losses.  But the problem is, sometimes the losses come in streaks, and you don’t have yourself a legit win for days and days.  You can’t do anything right, nobody cares about you, and it just sucks.  Those doldrums can be hard to see the other side of, and in all truth, if it were not for your classmates to help drag you through it, they can be darn near insurmountable.

In the ever so wise words of Firefly, “if you can’t run you crawl, and when you can’t do that you find someone to carry you.”