Posts Tagged ‘surgery’

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:

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.


Another Christmas Post

December 25, 2010

Once again I find myself in the semi-dark, sitting at the dining room table in my family’s house looking out over the lights of [the city]. Got some Christmas music going on Pandora, hot apple cider and warm slippers on my feet. It’s a peaceful place, and as I am sure you have all grown accustomed to, one suited to reflection.

The biggest thing on my horizon these days is figuring out the rank-order for the surgery residency programs I’ve interviewed at. I plan to interview at about 15 programs and in my head there are more or less two criteria; how good is this program/how good a fit is this program, and how difficult is it to get home from there. The ordering of these priorities is rather conflicting me at the moment. On the one hand I want to get the best surgical training I can, and enjoy the company of the half-dozen or so people I will be spending the next 5 years with . . . but on the other hand I realize my grandparents are not getting any younger and neither are my parents for that matter. And a lot can happen in five years. And on top of that, something like 80% of residents end up starting their practice within 100 miles of where they did their residency and I kind of like [my city], and yes the people who live in it (or at least come back to visit from time to time).

I anticipate my surgical residency to go for 5 years (possibly as many as 6 or 7 depending on whether I take time off to do research), working 80 hours a week for 48-50 weeks a year. As residents we are supposed to have 24 hours off every 7 days, averaged out over a few weeks. So I won’t exactly be rolling in the free time, and taking a plane flight home when you gotta be back in 36 hours is tricky.

And so the dilemma. I am not sure yet how these conflicting priorities are going to pan out. And despite all this premeditation, where I end up may well be completely random, as The Match works its algorithm and sticks me where it will.

Anyway. A few years back (on Christmas Eve if I do recall correctly) I had an entry talking about how I feel like medical school has changed me. If nothing else, I feel like I complain a lot more than I used to. I have struggled with this, trying to find a balance between getting stuff off of my chest/venting, and just being a whiny person losing his perspective. I chose this path intentionally; there was no coercion, no trickery. I knew it would be a lot of work, and I knew it would be stressful. I knew it would test me, and teach me about myself. Returning to home, I feel kind of like I am looking at an old photograph, or reading an old journal entry. It’s kind of like a window into the past a little bit, as if all the other stuff that has happened in my life away from here hadn’t occurred. It’s almost like a gauge, a marker that throws into relief how much I’ve changed, now that I am back in a place that has remained mostly the same in the seven and a half years since I’ve really lived here.

I think it’s telling, that in this context I feel more grouchier, more tired, and cynical and world weary than I remember. I snap at my parents more than I used to. What I perceive as personality flaws are more nettlesome. I look at my old bookshelves and I realize I’d forgotten how much I used to read. But I also feel a sense of pride, of accomplishment maybe even bordering on hubris. I find I still enjoy walking, and the lights of the city, talking with my parents and playing video games with my sister. I enjoy seeing my old friends.

Truly, I don’t know where this all is going. I suppose I already feel a bit uprooted, while I process all the changes from med school. And I worry a bit about how much more untethered from my proverbial roots I will become if I wind up somewhere else. But we’ve only got one life to lead and it’s almost always too short for anyone’s liking. And so why constrain myself to a certain geographical area, when there is so many more places of the country to explore? And when I may even find a better experience farther away, rather than close to home? Well, I suppose that’s the dilemma.

Anyhow, I wish all of you a Merry Christmas, and all the best in the new year.

Oh Surgery

June 22, 2010

After finishing my Emergency Medicine rotation a few weeks ago, I had a bit of a revelation that surgery is where I want to take my medical career.  EM was a lot of fun, don’t get me wrong.  But I always disliked how we never really fixed the sick patients.  If they were alright, we sent them home.  If they were really sick, we just held onto them until one of the in-hospital services could pick them up.  On my last day, there was a gentleman who was really very sick; he came in right at the turn of the shift, and so he had two shifts of EM docs working on him at the same time for almost an hour and a half to get him “stabilized.”  But then off he went to the MICU (medical intensive care unit), never to be seen or heard from again.  They paged a code to the MICU later that night, and one of the residents wondered aloud if that was our guy.  Who knows?  I found that aspect to be a little disappointing.

There are plenty of procedures in EM (I like procedures), and the shift-work lifestyle can be pretty awesome.  All the people I had the chance to work with were all very nice.  But you always give up your sick patients – you never really “fix” anyone, and the procedures are hurried, slap-together affairs because there are the other 20,000 patients out there waiting to be seen.  Plus there are the classic “emergency room specials,” the savory personalities that pervade every EM waiting room.

I appreciate that in surgery there is sort of a credo of personal responsibility.  Your incision, your patient.  And especially in critical care/SICU type work, the buck stops with you.  Patient goes from ER to the floor, and then if they’re too sick, they go from the floor to the ICU.  But once there, you gotta fix ’em.  No where else to put them.  And so they either get better . . . or they don’t.  :shrug:  That sort of mentality appeals to me.  I also love the feeling of cutting the sick right out of someone.  Peri-umbilical pain that turned into excruciating right lower quadrant pain a few hours ago?  Nausea, vomiting, fever?  Sounds like appendicitis to me.  Come on up to my OR and we’ll cut the sick right outta you!  And the mix of technical proficiency and medical knowledge.  Oh man.  Get excited just writing about it, lol.

So yeah.  It’s going to be surgery.  Get worried because of the hours, and the fact that I might end up like some of the people who come out of the process burnt out, angry shells of human beings.  But for the chance to do what they do . . . I think it’s worth the gamble.  We shall see.

In other news, I’ve been studying for the Step 2CK the last few weeks.  Kinda ready to get this over with, and move on to my SICU rotation in July.  oo rah!

Free Association Post!

February 7, 2010

It has been a while since I’ve last posted. I’m having a hard time pinning down specific things to talk about, so I figured I’d just let fly with the gestalt in my head.

I’ve been thinking about some of the memorable patients I’ve met over the course of the year. Single, earthy, elderly grandfather taking care of his two grandchildren. The girl who shot herself in the head, and the doctor who told her family. The really nice guy with inoperable pancreatic cancer. The other really nice guy who had the courage to joke about having his leg amputated. The sister and her mentally retarded brother who live together with her boyfriend, somehow making things work. The little girl with leukemia that we tried to send home for her birthday, but came back the next day to stay for four months. The man who lived in utter squalor at home with terminal cancer, that we kept in the hospital for two days against his will. The cancer patient who tried to leave AMA, trying to curse the doctors through his trach tube. The man who asked me when I’d be a doctor, and if he could be my patient. The woman that I tried to “give homework” to overcome her agorophobia by driving her son to school . . . and she succeeded. The 23 year old girl with a rare and terminal liver cancer. The little girl that we coded for two hours. The little boy with prune belly syndrome who smiled all the time.

I’ve been thinking a lot about surgery lately. About making it my career. I figure for some people, working 40 hours sucks because it’s just a job, and they spend another 40 hours chasing their hobbies and their passions. But if surgery is my job, my passion and my hobby. . . maybe that’s not so bad. I was told I was a low-average applicant, and I will need to do some solid work in the next six months or so if I want a shot at a good surgical residency in California. I am thinking that perhaps if I do surgery, I won’t necessarily get what I want, but maybe I will get what I need.

I have spent the last two Saturdays at the student run clinic I used to help direct. It’s amazing how far I’ve come since I was there a year and a half ago.  It’s kinda awesome realizing I have something to offer/something to teach.

My parents bought me this huge (for me) full size bed that I am luxuriating in each night.

I have started fencing again each Monday. It’s been so long, but the joy in that activity is still there. After practice this week, I went to dinner with some of the fencers afterwards. We all turned out to be grad students in one discipline or another. Was great to relax and be socially awkward in front of people who couldn’t care less.

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.


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?”


July 5, 2008

Starting the second year of medical school has meant that I’m one step closer to having do decide what to do with the rest of my life; what kind of doctor do I want to be, how much do I want to work, will I like what I do, will I have time for other things? Talking about different specialties, and now beginning to study specific subjects a bit more in depth (i.e Neurology and Dermatology), I can’t help but sense that coming decision at some point down the line.

As I sit now, the two big choices for me are between Emergency Medicine, and some surgical specialty (possibly trauma surgery or something like that). I think I want to care for acutely sick people; I like the idea that they are headed down some trajectory (hemorrhaging, heart attack, ketoacidotic crisis, etc etc) that ends in a bad outcome, but because of my intervention, I can push them back to something more . . . compatible with life. I like that in both specialties, I’ll have a chance to see a wide variety of people and diseases, and work with a relatively diverse team. I get to use my hands, and be able to literally ‘fix’ someone because of them. I feel like both those specialties speak to what I want out to my career.

But then there is the nature of the work. Emergency Medicine docs do shift work; they do something like 12 hours on, 12 off for 3 or 4 days, and then have the rest of the week free. They carry beepers, but only when there is something like a train wreck, earthquake or an unplanned street luge contest do they ever get called in during their time off. Emergency medicine means you get to see everyone and everything; people come up with all sorts of creative ways to hurt themselves, and I think it requires some creativity to fix them. EM docs are also jacks of all trades; they’re good at treating about anything that could possibly come in the doors . . . for about an hour and after that they needs someone else to help them out. They don’t build particularly long relationships with their patients, and more often then not they need to check on the patient via the computer to see how they’re doing.

The trauma surgeons of the world however, get called down when something particularly nasty happens to someone, and it is their job to crack open that someone’s chest to get at their lacerated sub-clavicular artery, or bundle them off to surgery to repair their bleeding liver. My understanding is that they care for these people from when they are called into the ER to when they are discharged from the hospital. The trauma docs supervise them in the surgical ICU, monitor their progress, and see to their recovery. But more than all of that, surgery (to quote :shudder: Gray’s Anatomy) is the marines; you work really hard, but it means you get to do some crazy stuff. All my life, I think I’ve tried to choose that path, following the philosophy that if anything is worth doing, it’s worth going all out for it. If you are gonna be a student, might as well be as good a student as you can be. If you are going to play soccer, you should play as hard and as good as you know how. One should challenge and push themselves throughout life, and so if you are going to be a doctor, why not pick the most intense, challenging field? I think medical school selects for those personalities; the people who like to work hard and push themselves. Medical students are competitive and hard working by nature, and I don’t feel like I am any exception.

I think medicine is really my passion in life, and if I can’t do that to the fullest, than what’s the point really? Surgery would mean a hard-working life, and one that might mean sacrificing some important things. And to be honest, that’s a little scary. I’m in my early 20s for goodnessake; what do I know about having a family, or living a life outside of academia? I don’t want to let those important things pass me by. It’s like not going to prom in high school or something; everyone else has done it, and so you feel like you’re missing out on some common experience that everyone else has had.

Anyway. That’s been my dilemma of late, thinking about those sort of big decisions lurking just over the horizon. Maybe it’s like choosing colleges, and it doesn’t really matter all that much where you go, you’ll have a good time anyway. On the other hand, I really don’t want to screw this up. :shrugs: For all I know, in my third year I might fall in love with ob-gyn, and this will all be useless speculation. I guess we shall see.