White Collar and Blue Collar Surgery

As part of our surgical residency, we are required to have some experience with transplant surgery.  In different programs this takes different forms (as an intern, a 3rd year or 4th year resident, etc) but it is a requirement all the same.  My home program does not do transplant surgery, and so for me it means traveling to another city to a bigger, much more academic hospital that does.  My roles on the transplant services at this hospital are somewhat vague but what is well understood is that I go on donor runs.  These donor runs represent only a small fraction of the resources that are devoted to the goal of taking organs from one person and putting them into someone else . . . but holy moly are they neat.

The general outline of how this works is a local hospital identifies a patient that might be eligible to donate their organs (they might be brain dead or the family wants to withdraw care) to the local donor network.  This local donor network team then contacts the patient’s family, and if they are indeed interested in donating, takes over care of the patient and begins the process of evaluating the patient’s organs for eligibility for donation, and distributing the information to different transplant programs depending on which program has a patient at the top of the recipient list.  It is then up to the on-call transplant surgeon to make the determination as to whether the organ (in addition to the immunologic matching) would be a good match for their patient.  Sometimes the organ is accepted, sometimes it is declined and the next transplant program with the next patient on the list is contacted and so on.  There is additional wrangling than I can’t pretend to understand, but if my program decides the organ would be a good match, then usually they send the procurement team to go get the organs and bring them back.

That’s where I come in.  Generally the “team” consists of a transplant fellow (general surgeon learning to be a transplant surgeon), a transplant coordinator, and myself.  These calls can come at any time, but when they do we all meet in front of the hospital, get into the chartered van which then takes us to the hospital (if it’s close) or to the airport (if it’s not).  If we go to the airport, we cruise through to the executive terminal and get on some small Buddy Holly-sized corporate-type jet and zoom off into the wild blue yonder to the airport nearest the hospital of interest.  Another chartered vehicle picks us up from the airport and off we go to the local hospital.  When you roll into the local hospital, it’s hard to get away from that action-movie, characters-all-walking-in-line-abreast-in-slow-motion-as-dramatic-music-plays vibe.  We’re like “The Transplant Team” (yes in capital letters) and you feel like a little bit of a badass.  But anyhow.

We go to the OR and get everything ready, check the paperwork, and then it’s go time.  The hospital staff brings the patient to the OR.  This patient is a person who has been declared brain dead and who had the desire to donate their organs in the event that they had no further use for them but others may yet benefit.  It’s very clinical, getting the patient positioned, shaved and prepared for the surgery.  But before it’s time to start there is always a moment of silence, where sometimes a passage that the patient’s family wrote about the patient is read or, if there is no such passage, everyone in the OR takes a moment and is quiet in respect.  I don’t know about the other people in the room but I’ve found these moments to be very poignant and a little haunting.  I am not a spiritual person, but that hasn’t kept me from sending good thoughts in the patient’s direction.

I always thought that this particular xkcd comic summed the whole donation philosophy nicely: http://www.xkcd.com/659/

We then perform the procurement procedure.  There is a point in the process where the patient is ‘vented’ or all the blood is removed, the patient is cooled, and the organs to be transplanted are filled with a preservative fluid.  It’s at that point that the patient’s heart stops beating, and the anesthesiologist shuts down their machine and leaves the OR.  This is also something of an emotional landmark of the case, watching the heart wind down and then stop.  Intellectually you understood that they were dead before, but seeing the heart still in their chest makes it much more real.

Once the organs are safely in their boxes, we carry them back with us to the plane, go back home, and bring them to the hospital where the surgery team is waiting to transplant the organ into a waiting patient.  It’s a neat process, and I once was able to follow a kidney, removing it from the donor, back to the transplanting hospital, and then got to help sew in the kidney and see it start making urine.  No lie, it was pretty neat.

This also brings me to some of the differences in surgical training programs.  I read in a book somewhere, someone referring to themselves as a “blue collar” surgeon.  This appellation and the implication that there was thus a “white collar” surgeon and that they were somehow different.  The big, academic hospital where I did my transplant rotation definitely was training “white collar” surgeons.  Among the faculty were some of the world’s experts on transplant surgery.  The other surgery divisions also like-wise had some of the foremost experts in their field.  The residents all had some experience with some of the most advanced surgical techniques, procedures, medications, treatment regimens yet invented (and some still experimental).  The exposure these residents had, and the opportunity to learn about state-of-the-art, cutting edge surgery is amazing, and in some ways I was a little jealous.  Coming from my home program, which is located in a poorer county with a higher immigrant population, and with a less “academic” reputation, I could not help but feel a bit like a Crocodile Dundee.  A little rural and a little backwards, but nevertheless with my own, effective way of getting the job done. (You call that a scalpel?  THIS is a scalpel!)

My home program I like to think of as doing much more “blue collar” surgery.  There is no bench research where I come from, no mouse models or transplant surgery.  In place of that expertise, we become experts in treating the common surgical diseases.  Learning through volume what the rare presentation of a common surgical disease may look like, how to make headway in a technically difficult case, and making progress in the pursuit of perfection by the act of continuous repetition.  Furthermore, in a place with relatively few consulting services, many times it’s left to us to figure things out for ourselves, to learn how to manage aspects of patient care that might be otherwise consigned to a consultant.

Which model is the best?  It’s hard to say.  If I need my kidney transplanted, I would certainly choose the white collar.  But if I’m shot in the chest, I’d go with the blue collar any day.  They say that in the match you often find yourself going not to the program you want, but to the program you need.  Leaving the academic hospital and coming back to my home program, I could not agree more.  There are people perfect for one place, and people perfect for another, but I’m grateful that I found the proper place for my training.

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