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White Collar and Blue Collar Surgery

March 6, 2014

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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Jiro Dreams of Sushi

February 8, 2013

Wow.  It’s been a long time since I’ve posted to this blog.  Five months is a long time.

At the moment I am sitting at one of those watershed points between services; finished with one service this morning, moving on to the next one tomorrow.  Such times are good for reflecting.

I am just finishing five months in the Intensive Care Unit on one service or another, taking care of very sick surgical patients.  The services have been busy, and for some it has required me to work nights.  I think I’ve thoroughly enjoyed my time on those services, but I admit that towards the end I was starting to feel a little burnt out.

On an extremely quiet night on call a few weeks ago, I watched Jiro Dreams of Sushi.  It’s a charming documentary about a master sushi chef in Japan.  This man is in his mid-80’s, and has committed his life to making the best sushi he can.  Day in and day out he works up that asymptotic slope towards perfecting his sushi making.  Indeed, in the documentary he talks about how he would wake up in the middle of the night, having dreamed of some new sushi recipe or technique that he wanted to try (hence the title of the movie).

I felt like one of the take-home points of the movie is that there is a sort of Zen beauty in doing one task and doing it very very well.  That there is a good-ness to be had in a simple life devoted to the pursuit of perfection.  Of course, being on call for surgery as I was, I couldn’t help but draw comparisons between the movie and my chosen career.  Much like Jiro’s pursuit of perfection in sushi making, surgery demands a certain monastic devotion.  In your training, and I suspect a large part in your practice, surgery isn’t so much a job as it is a permanent fixture in your life.  There is an expectation that you should spend free time reading, tying knots, reading, working on research projects, reading some more, and oh yeah probably reading (and I don’t mean like Harry Potter, I mean like surgery textbooks).  There are times when I actively feel guilty about taking free time for myself.  Because I mean c’mon, I could be 1) playing video games, or 2) learning how to save people’s lives better.  How hard can the choice be right?

I find that I spend a fair amount of time with the emergency medicine residents.  Their time is much more delineated, broken down into shifts and schedules laid out weeks and months in advance.  They work their butts off during their shifts, and then they go home.  They are (in my life anyway) the principal planners of events, the people who host the parties and send out the invites.  They have diverse interests; they renovate their houses, travel, rock climb, garden, go skiing, have husbands and wives.  They keep pets.  They have stories.

Listening to them regale me with their latest adventure skiing in Patagonia, I can’t help but feel that perhaps I am missing something.  That in this sushi master-esque pursuit of surgical perfection (and as my attendings will be quick to remind me, I have a long pursuit yet to go) perhaps I’m forgoing that beautiful variety of experiences one can have in life.

It’s hard to say.  Part of me wants to believe that I can have my cake and eat it too, that perhaps I won’t waste my twenties and early thirties, and in what little spare time I have I may be able to cram in some quality experiences.  I mean, one of the reasons I chose surgery is that I felt I wouldn’t know what to do with my free time.  The jury is still out as to which lifestyle is better.  But I console myself a little bit, thinking that yes, maybe it is possible to do both.  We shall see.

Ten Thousand Knots

September 4, 2012

Hey everyone.  Sorry it has been so long since my last post but now that I have some time, I thought it would be nice to commit some of the thoughts rattling around in my head to “paper.”

Presently I’m at the VA, and it has been quite an experience, but I think I will be glad when I go back to the “mothership.”

One thing that has happened at the VA though, is that I think I am slowly coming to terms with the process of learning to be a surgeon.  I am not going to be perfect every time, and berating myself every time I fall short of that goal is not going to be productive, nor mentally healthy.  The drive to be good for my patients will always be there regardless, but adding on the self-deprecation when my fingers slip tying a knot or I forget to enter an order helps nobody.  Starting my second year, I think it has given me a little bit of prospective; I am far enough from where I started that I can see where I came from, and how far I’ve already come, while at the same time I have an appreciation of how far I have yet to go.

My soccer coach back in high school said that in order to be a good soccer player, you need to get touches on the ball.  Over and over, you had to get those touches.  Juggle it, pass it, touch it.  Learn how it moves over the grass, how it feels on your foot.  He said that whether we had formal practice or not, every day we had to get some touches in on the ball if we ever wanted to be good soccer players.

Well, I wasn’t a good soccer player, and indeed I quit the soccer team early on in my senior year because I saw that the younger classmen were going to be starting, and I’d be spending another season on the bench (My coach, bless his heart, let me keep my jersey even though I told him I was planning to quit.  He was a classy man).  But now I think I finally understand what he meant by getting in those touches.  There is a saying in surgery, that you need to throw ten-thousand knots before you can consider yourself proficient.  The number isn’t what is important.  But it is the idea that it is going to require a daily commitment, for a long long time, to master surgery.  Maybe it will be tying knots at home, or reading in a textbook or looking up an article.  But surgery is an art, and like soccer it needs to be handled every day if you want to have any hope of being good.  The way my attendings tie, the suture seems to obey their will without any conscious thought.  It’s effortless.  They have gotten so good that every little subtle motion, the tension and the feel, it’s all so deeply ingrained in them they think about it with the same consciousness as they do breathing.  And of course I struggle mightily.

But know I understand how it works.  A journey of 10,000 knots if you will.  Scrubbing into cases that I wasn’t interested in used to be a chore, but now I understand their purpose.  Of course nobody is interested in all the cases all the time.  But now I see that every case is a chance to throw some more knots, to handle more suture, to hold the instruments and feel the tissues.  Somehow coming to that understanding has made things so different in my mind.  I can place myself now on the route of how I get to where the attendings are.  It’s a long long way to go but I can see it and that was a big moment for me when I understood that.

The Right Stuff

June 5, 2012

We had a meeting this morning for us interns.  It was a kind of “getting ready for second year” meeting/pep-talk that I suspect left most of us more terrified than when we started.  At least at this program, it is a commonly held opinion that our second year and our fourth year are the hardest years.  Our second year is difficult because as an intern nobody really expects you to know anything, or be able to do much of anything alone.  But as a second year, they expect that you’ve learned something from that internship, and they expect you to apply it.  Now you are expected to make some judgements, and do some basic procedures, on your own.  I’ll be starting on a rotation with only three house officers running the entire service.  No cross-cover, no back up residents.  It’s just the three of us managing a service.  And so when I get called in at night to evaluate a patient in the emergency department, it’ll be my judgement alone that determines whether to wake the attending up, or if it can wait until morning.  This and a million other things make second year a daunting one.

As if to call that all into relief, there was an ED thoracotomy today.  I was helping on the periphery for most of it, but I think for the first time I really put myself into the shoes of the people whacking through the ribs, and rummaging around in the patient’s thorax looking for his aorta to cross clamp.  It was pretty intense.  The man hit the door, and to my inexperienced eyes he looked like most other trauma patients.  Unhappy maybe, but not life threatening.  Our department chair was around, and it was impressive watching him work.  He sensed something almost the moment the patient was in the room, that something was wrong.  Like I said, to me he just looked like any other agitated, struggling patient, worked up because it hurt and people were coming at him with pointy needles.  There was nearly no IV access, and the single line the paramedics had put in blew.  The patient continued to struggle, but out chair gabbed a central line kit and I shit you not had the fem line in in less than 20 seconds.  The nurse called out a blood pressure of fifty over palp, and right away our chair was at his side with his knife ready to start the thoracotomy.  I don’t know how he knew the patient was going to head south, but he did and in seconds the patient’s chest was flayed open and they were searching for the bleeding.  I helped one of our chiefs put in a second fem line, and bagged the patient on the way up into the OR (the ED nurses can’t enter the OR with their scubs I guess).  The patient did poorly, and they suspect he had gotten air embolized into his coronaries and the rest of his circulation from the gunshot into his lung.  They shocked him with the internal paddles, and I saw the anesthesiologist give an intra-cardiac shot of epinephrine (the old school needle-into-the-heart craziness).  They went on massaging his heart for maybe 30 minutes, but after that it was obvious things were futile and so they called it.

I don’t know how to describe how impressive it was, seeing arguably our hospital’s best surgeon kick it into high gear.  He knew the patient was going south using senses totally unknown to me.  I guess it’s a gestalt, something a combination of experience and talent lends you.  But thinking about myself, and being in that situation, it staggers me.  Theoretically he is what the program is trying to produce, and the idea of being like that is both amazing and terrifying.  I couldn’t even rouse myself to help put in a central line.  Someone with larger testicles might have actually tried, to see how far you’d get before you got hip checked.  I don’t know.

I hope I’ve got “the right stuff.”  That’s all.

Working Hard and MASH T-shirts

February 19, 2012

It’s been a long time since my last post, and a lot has happened since then.  So much so that I don’t think half a dozen posts could do the events justice.  But at the least I can try to give a bit of a flavor, a beer-sampler if you will, of the past several months.

If there was one word to describe the passed time, it would be “busy.”  Surgical residents are nothing if not busy.  I’ve rotated through the VA hospital, the general surgery service and anesthesiology since my last update, and I’m now nearly two weeks into my SICU rotation.  With the gross exception of anesthesiology, all have kept me extremely busy.

I think one of the things I struggle with is finding understanding from my (non-medical) friends.  I take my job very seriously, and I work very hard.  When I go home I want to relax and joke about things, but sometimes I want to talk about some of the heavy stuff, and I have a hard time finding good understanding from those people in my life who don’t have medicine as their career.  I work 70 or 80 hours a week, and it’s easy to see the number in your head, but understanding what it actually means in real life terms is something else.  At the end of a 13 hour day you’re tired.  I regularly buy dinner from the hospital cafeteria because I don’t have the time to go grocery shopping.

And the work is stressful.  I desperately want to be good at this job, but there are always little mistakes.  So far nothing too harmful (thank goodness) but it’s very frustrating to work so hard and still screw up, and even more worrisome knowing that the day may well be coming when your mistake will cause someone harm.

And patients die.  Not long ago I was speaking to a man with an actively rupturing abdominal aortic aneurism.  He was stable at the time, but I left the room to discuss him with my boss, only to return to find his mental status altered.  He was quickly intubated and taken to the operating room, but there he died on the table (longer version of this story to come).  These dramatic things don’t happen every day, but they do happen.  Patients that I’ve taken care of for weeks suddenly die.  You meet their family, get to know who they are.  These people trust you.

But then there are days like to day.  It’s my day off and I am sitting outside my little dwelling, with my MASH t-shirt on in the sunlight.  Sipping a soda and taking a break from some pleasure reading to update my blog.  I wouldn’t trade this crazy life for anything.

Sphincter Tone

October 18, 2011

Today was my last day on the Trauma service until the spring. I was up in one of the hospital wards seeing a patient, when one of the patients a few beds down started having runs of v-tach (or ventricular tachycardia). This is a heart rhythm that, if sustained, can kill you.

Now I was standing a few feet away and heard the nurses talking so I came over and saw that it was true, and people were starting to get a little wound up because again, v-tach = bad. The nurses called the patient’s doctor (I have never met the patient before), but being the closest doctor on hand I felt some obligation to do my doctor thing. So had the nurses put the patient on the heart monitor/defibrillator, stick a non-rebreather mask on him, draw labs and monitor his blood pressure. Everyone was kind of wound up because he’d have these runs of v-tach, then he’d snap out of it again. The runs weren’t much longer than maybe 20 or 30 seconds, but when it’s a potentially fatal arrythmia, it’s scary. The patient himself was groggy and not really with it, but he was conscious. I was more or less keeping one eye on the monitor and the other on him, because if ever it got bad enough that he lost consciousness/lost his pulse, we’d need to shock him and start CPR.

It was about at that point that I took out my little book that I carry with me to look up the amount of energy that we’d need to use to shock him (turns out it’s about 120 Joules), and to remind me as to what additional steps we’d have to take if indeed he lost his pulse, but I had to laugh at that point because I was literally flipping through the proverbial textbook to find the answer to this real life question. Good thing no family was there to see me.

Anyway, he’d have these runs of v-tach and then snap out over and over again for what felt like forever. Finally his doctor (someone who knew something about the patient) showed up, he called the medical ICU and sort of took over.

I’ve practiced this sort of scenario on mannequins a fair amount. But I’ve never been in this scenario before where I was in the position of having to run the thing on a real patient (I’ve been other doctors’ helper-minion many times, but never in the role of the one in charge).

The patient made it up to the MICU safely, I didn’t do anything terribly stupid (although in retrospect I could have done some things that might have been smarter), and yeah. It scared me shitless.

New Blog Name and Big Boy Pants

October 18, 2011

It’s been a while since I’ve updated.  But in my defense, I’ve been busy.

With my graduation from medical school and the start of my surgical residency, I felt it only appropriate that I re-christen the blog.  I liked the name “Second String Hero” because I think that in a lot of ways, it sums up how I feel about residency.  You’re not the best.  You’re learning.  You are not the master of the knowledge that you are practicing.  Indeed, you’re learning how to be a good doctor, to be a good surgeon.  Everything is mildly uncomfortable, everything is new.  When you master one skill set, you move on to learn another.  There is rarely time to settle down and rest upon the comfort of your hard-won knowledge.  No, it’s up and at ’em again, to climb another hill of learning.  But in order to grow into those big boy pants, you first have to don them being a few sizes too small.  You have to be placed in roles that are a little above your head, a little out of your comfort zone.  And you have to try and fill the role, and through that trying (and sometimes failing) you learn.  And with time, you come to fill that role, master the knowledge.  But by then it’s time to move on, new role, new growth, more discomfort and more scrambling to learn.

And so I feel like all through my education that is in some way what I am.  A boy too small for his britches, trying to fill those big boy pants and not let on that I’m doing a job that is almost too big for me.  I am not the best choice for most of these jobs; that is the point.  I am supposed to learn.  And so hence the name, Second String Hero.

That, plus it sounds mighty catchy.

This is Ourselves, Under Pressure (or First Week of Third Year)

May 9, 2009

Well, third year officially started about a week ago, and by all apperances it seems I am still here to tell the tale.  But no lie, this week feels like it could fill a month.  Last Friday we began orientation to third year, and Monday I had my pediatrics clerkship orientation (it’s my first rotation).  I am assigned to the team taking care of the pediatric hematology-oncology ward (read: kids with cancer) with (in rough order of seniority) another fellow third year, an exchange student from Japan, a fourth year, an intern, a second year resident and an attending.  There are only 8 or 10 patients on our service, so the Japanese medical student, and us two third years are responsible for ‘only’ one patient.

I use the quotation marks there because even now, a week later, we are still struggling to figure out such simple things as how to access the appropriate records and how to present in a manner that doesn’t provoke the wrath of our attending.  Needless to say, it’s a good day when, between my third year colleauge and I, we can find the elevator to get from one floor of the hospital to another (I’ve given up on finding the stairs).  And to make it all worse, our utter ineptitude slows the work of the team down to a pace cold molasses might surpass.  In the colorful words of my old high school soccer coach, we’re “as useless as tits on a bull” and for someone who desparately wants to be of use to those around him, it’s kina irksome.

But yeah, I think I’ll just tell you guys about what an average day looks like on our peds heme-onc service.

The day starts at 4:45am when my alarm goes off, so I can get to the hospital a little before 6 to pre-round (check up on, in medical-ese) on my single patient.  For the next hour or so, I check her labs, speak to her nurse, slip in quietly to actually see her and do a brief physical exam, then settle down to try and hammer out a progress note summarizing my physical, any new labs, the pertinent events from the last 24 hours and so on.  Taking that, I am theoretically then supposed to formulate a plan for my patient for the day . . . which usually turns into the clinical equivalent of a five year old’s attempt to design the Lourvre.  After that we meet with the night float team and hear their quick summary of the patients on our service.  Then at around 7:30 we practice our presentations with our intern, scurry off to Morning Report, where one of the pediatrics residents presents an interesting case seen recently in the hospital.  At 8 or 8:30 the attending arrives, and we round on our patients, updating him on the events of the last 24 hours for each of the patients.  These labs came back, patient X developed a fever, patient Y was admitted, patient Z seems to be tolerating her chemo well, etc etc.  Then we explain to him the treatment plan we’d like to institute for the day, and go visit each of the patients again with the attending.

It is here during rounds that we get pimped (so far pretty gently), reprimanded for not presenting data correctly, or chucked at for suggesting outlandish or grossly inappropriate treatments for our patients.  (By the way, ‘pimping’ in medicine describes the ritual of the attending asking questions of med students or other members of the team.  “Why did we order the magnesium levels on patient z?” “How much would you expect the hemoglobin of patient x to change if we transfused him with 2 units of blood?” etc etc.  Not the other thing.).  Because of our painful deficit in clinical knowleage, presenting skill and general medical know-how, rounds usually drag on until 12 or later, until we zoom off for (what has lately been) a ten minute lunch and return to sit for a Journal Club or some other noon-time conference that usually has materiel waaaaay over my medical student head.  Then the afternoon is spent ‘making things happen,’ calling consults, ordering labs and meds, and so on.  If we are lucky and do our work quickly, we update the attending again in the later afternoon regarding any changes . . . or we keep on taking care of the work we were suppposed to do, but because of the medical student dead weight, is still being worked on.  Then at around 5 or so the intern and resident excuse us to head home to study about the 10,000 things we didn’t understand, eat, maybe watch a Scrubs episode, then to bed to repeat the next day.  This goes on for six days a week.

I promise there is a lot more to all of these things than I am writing here.  Sick, sad children with cancer being pretty high on the list, as well as what it feels like to ostenibly take care of them, and to finally be in the hosptial.  I promise there is more to come in the future, but I think that’s all I can muster for now.  More to come.

Be Back Soon!

March 30, 2009

Just wanted to let y’all know that I’ve been studying for Step 1 of the USMLE for the last month or so . . . hence the dearth of posts. I promise once I’m done in a few weeks, I’ll be back to posting! Until then, take care!

Good Bye Xanga, Hello WordPress

July 3, 2008

Well, I think it’s finally time to throw in the towel with my xanga account. One too many times has the darn thing asked me to take a stupid poll or nearly deleted all of my posts. Plus, it just looks ugly. So until I can find a way to import my posts (which may or may not be possible), here is the link to the old site. Sorta sad to say goodbye; I’ve been making entries there since I graduated from high school. But life goes on, and here I am. Let’s hope my relationship here with wordpress is as prolific and long lived as the last with xanga.

Here’s the old link:

http://www.xanga.com/ChevalierMalFet