Surgery Synopsis

Surgery is over. I enjoyed it, but I'm glad it's over.

I was on vascular surgery at Parkland. A typical week would start out at about 4:45 on Monday morning. I would pre-round on my patients and make a sheet for my residents and attending with all the vital signs of all our patients. Then we would round with the residents and then with the fellow. After rounding with the fellow, sometimes we had 15 minutes to grab breakfast and run to clinic.

Clinic was always chaotic. There were 6 students, 4 residents, 1 fellow, and 1 attending in clinic. The students saw patents, presented them to someone more qualified, and then wrote a note. It was interesting to follow up on patients that had previous surgeries and see how it looked to care for a patient that was a few weeks post op. I got to take out some staples and look at some fresh amputations.

I feel like we did a lot of that in vascular surgery. If we couldn't reestablish blood flow, we would cut someone's leg off. Sad, but I guess it's what has to happen.

I also got to look at how a pre-op history and physical exam works. I figured out all the "important" H&P questions that the attending really needs to make sure you ask and document: "Are you taking any ASA or blood thinners?" "Have you had recent chest pain/ trouble breathing?" Etc.

And I got REALLY proficient at finding someone's pulses, either with my fingers or with a Doppler, which is an ultrasound wave you can hear. I learned to differentiate between triphasic, biphasic, and monophasic pulses. I began to recognize the difference between arterial and venous problems. And the plan to treat people with those problems. I also got good at using the electronic medical records system. It took a while to figure out where everything was, and I had to ask a lot of questions, but eventually it became pretty easy.

After clinic on Monday, we would all eat lunch in the cafeteria with our attending doctor and he would lecture us on a vascular issue. I loved listening to him, because he was so knowledgeable and he would tell us everything and then let us ask questions.

Most other days we pre-rounded, rounded, and went to watch a surgery. Or went to watch a surgery get cancelled. I scrubbed in to 2 cases. I got to watch a few more from the OR, but with 3 students and 1 attending, it was hard to have enough to scrub in to.

Wednesdays were fun. We had lecture from 7 am to noon, then lunch. I got to work in small groups with med students for 2 sessions each morning and we discussed practice patients. I enjoyed getting to talk through patients. I felt like I learned a lot! I also got to work with Dr. McClellen and have tutorial sessions with him on Wednesday and Friday afternoons. We would each present a topic and then talk through it with our group. He had a lot of wisdom to share with us.

My fist surgery was lame. It was endovascular, so I got to watch them stick wires up a man's groin to his carotid artery. I didn't touch anything. It was neat to wear lead and watch the screen to see where the wires were going. I liked getting to read about a procedure before and then see it in action.

2^nd scrub: intimidating. Still not sure exactly what to do. Or even really why scrubbing is SO important if we rinse our hands in non-sterile water and then put them inside of 2 layers of sterile gloves. It was a lot cooler. They cut the patient's whole stomach open and made 2 cuts in each groin. They let me stick my hand up one of the groin cuts into her abdomen. It was neat to feel the inside of someone! I liked getting to watch them cut and then sew in a graft to the aorta and then connect it to her femoral artery. My favorite part was watching the graft pulsate when they let blood flow through it! They let me staple the woman's abdomen. I need a bit more practice with staples before I'm good enough at it!

Coolest thing: Getting to be part of a patient care team. Being asked to change wound dressings and using that time to make sure the patient didn't have any questions and answering them when they did. Gettting to watch the patient's face when the resident "explained" something, and then going back to see the patient and spending time to actually make sure that they understood what the resident was talking about earlier and they were too scared to ask questions about.

I liked getting to work on a team and be a part of something. Working with Med students, doctors, nurses, PT and OT, I really got to see how a patient moved from a clinic appointment, to surgery, then to another clinic appointment where their problems were resolved.

I liked surgery, but I don't think it is what I want to do. The OR is too high stress. And So disconnected from patient contact. Most procedures your patient is asleep for!

Weekend Shifts.

Chill.

No Surgeries. (not that we do many surgeries during the week)

Now I'm getting ready for the last 1.5 weeks, our 2nd Attending comes back into town so we should see some more cases.  Hopefully.  :)

Weekends are too short.

Ten

Ten people rounded yesterday:
1 attending
1 fellow
1 resident (3rd year)
1 intern (1st year)
1 Sub-I (4th year med student)
3 MS 3s
2 PAs

That's a lot of people to cram in one room for rounds.  Or at one lunch table for an info session about chronic limb ischemia.

Scrubbing In!

So I got to scrub in today. On a carotid stent placement.

After peeling myself out of bed at 4 am (I've been having this internal debate: is 4 am still night, or is it morning? Because clearly, 5 am is morning. Sometimes people wake up at 5 am. And clearly 3 am is still night. I've been out partying at 3 before. But 4 is an in-between. A no-man's land. Unless you're a surgical student/ intern.) I got to the hospital and rounded on my patients.

Then rounded again with the intern. Then again (quickly) with the fellow. Then I followed the fellow to the OR to surgery. The MS3 and Sub I (*See The Hierarchy of Medicine, at the end) let me scrub in because I never had before. And I was pretty excited.

Beyond excited, really J

First, I grabbed gloves and handed them to the scrub nurse. Then I got dressed up in a led vest/skirt combo. Everyone in the room had to wear one since we were doing a procedure where we would be shooting a lot of x-rays in the air. They were heavy, but I thought they looked cute. I wish I had a picture to explain them better. Here's one I found on the internet. Ours were like the turquoise one. Except they were black, blue, or green. All I kept thinking was that they would make a cute dress.



Since I had never scrubbed in before I followed the Fellow around and scrubbed with him. "Scrubbing in" is basically just where you wash your hands and arms really well. Then you be VERY careful not to touch anything and move into the OR. The scrub nurse helps you into an operating gown and then into your gloves. I wore 2 pairs of gloves, but my attending/fellow only wore one. Maybe because it wasn't a big procedure. I'm not sure.

But picture it like Grey's Anatomy: you have on your scrub hat and mask, then wash your hands (for a long time), then hold your arms out and in front of you because they're now sterile. Except we didn't look nearly as cute. Again, I wish I had pictures.

Since we wore masks, you could only really see anyone's eyes. I found it really interesting that eyes could say so much! The nurse (not the scrub nurse, the other one that was running for supplies) and I had total conversations with her eyes. She was sweet. She was about the only one who cared that it was my first surgery so she kept checking on me to see if I was ok.

We were placing a stent in someone's carotid artery (the big artery in your neck) but going in from the femoral artery (the big artery in your groin). Basically, the surgeons kept putting wires and tubes into the patient's groin and taking x-ray pictures to see where in the body they were until they got the wires up to the neck.

At the beginning of surgery all I really did was help hold wires for the surgeons. I didn't even help hand things to and from the scrub table (the scrub nurse wasn't very nice to students) I got pretty good at it. But towards the end of surgery the patient was trying to reach up and grab the guidewires (they don't put people under because they are usually high risk of an acute event like a heart attack or stroke), so I got to hold his hand. I think that made him feel better.

I did a lot of watching wires moving in and out of our patient. I didn't really count, and I didn't know about the procedure to do research in advance, but doing research after, it looks like this:

1. Access into the femoral artery in the leg (or, less commonly, into the radial artery or brachial artery in the arm) is created by a device called an "introducer needle". This procedure is often termed percutaneous access.
2. Once access into the artery is gained, a "sheath introducer" is placed in the opening to keep the artery open and control bleeding.
3. Through this sheath, a long, flexible, soft plastic tube called a "guiding catheter" is pushed. The tip of the guiding catheter is placed at the mouth of the coronary artery. The guiding catheter also allows for radiopaque dyes (usually iodine based) to be injected into the coronary artery, so that the disease state and location can be readily assessed using real time x-ray visualization.
4. During the x-ray visualization, the cardiologist estimates the size of the coronary artery and selects the type of balloon catheter and coronary guidewire that will be used during the case. Heparin (a "blood thinner" or medicine used to prevent the formation of clots) is given to maintain blood flow.
5. The coronary guidewire, which is an extremely thin wire with a radio-opaque flexible tip, is inserted through the guiding catheter and into the coronary artery. While visualizing again by real-time x-ray imaging, the cardiologist guides the wire through the coronary artery to the site of the stenosis or blockage. The tip of the wire is then passed across the blockage. The cardiologist controls the movement and direction of the guide wire by gently manipulating the end that sits outside the patient through twisting of the guidewire.
6. While the guidewire is in place, it now acts as the pathway to the stenosis. The tip of the angioplasty or balloon catheter is hollow and is then inserted at the back of the guidewire—thus the guidewire is now inside of the angioplasty catheter. The angioplasty catheter is gently pushed forward, until the deflated balloon is inside of the blockage.
7. The balloon is then inflated, and it compresses the atheromatous plaque and stretches the artery wall to expand.
8. If an expandable wire mesh tube (stent) was on the balloon, then the stent will be implanted (left behind) to support the new stretched open position of the artery from the inside.^[11]
   

(Wikipedia: Percutaneous Intervention: PCI)

We also had a close call today: The patient sat up in surgery (we don't put the people all the way to sleep) and he knocked something our of place, causing a clot to move into his brain.  Thankfully, the neurosurgeons came quickly, we got the clot broken up, and life went back to ok.  The neurosurgeon had a really cute lead outfit, it made me smile :)



The Short Version of Today:

I got to wear a lead vest, 2 pairs of gloves, and a gown only to stand and watch as they passed a bunch of tubes and wires up to this guy's neck through his groin. It was slightly anticlimactic. Maybe I'll get to scrub in on a more exciting surgery in the future.





I also got to do a vascular consult on a sweet old lady who had some leg ulcers. I expected her to be larger, have diabetes and a bunch of other medical problems, but she wasn't. She had no past medical or surgical history. Or family history. But her leg ulcers were SO bad. She was showing her achillies tendon and bone on one ankle. After I examined her, I reported her to my intern and fellow, and then they went to see her. And my fellow abruptly told her amputation was the best option. He wasn't mean, just sudden.

When I went back she was clearly upset. It was too abrupt. She wasn't ready to let go of it yet. She wasn't ready to picture how her life would look without it. It made me almost cry thinking about things I've let go of suddenly. It's not fun. Or fair, but life isn't fair.

I realized today how quickly things can be gone. How we can't hold anything secure. Not the ability to speak, like in my surgery case, not limbs, not people. But life goes on, and we learn to adjust. Even if it does take a while and make us upset every now and then.





*The Hierarchy of Medicine:

Attending Physician: What you see on Grey's Anatomy, essentially (Slone, Sheppard, Hunt, Etc.)

Fellow: A doctor who finished residency and is now doing extensive studying in something (not all specialties have fellows)

Resident: 2^nd/3^rd/4^th year after graduation from Medical school. Essentially, they're still learning a bit, but they get paid now. And they have a lot of responsibility.

Intern: 1^st year resident, who essentially, has it pretty bad. I think they sleep less than I do.

Med Student 4 (MS4)/ Sub-Intern (Sub I): They have a bit more freedom than MS3s and PA-Ss do. They get to do more fun rotations and stuff.

Med Student 3 (MS3)/ Physician Assistant Student (PA-S): we sit on the bottom of the totem pole and do all the "scutt work." So they sometimes refer to us as "scuttpuppies." We get all the labs, write notes, and report to the millions above us.