Medical School 2020, Year 3, Week 1

Eight of us arrive Monday at 6:00 am for surgery rotation orientation in a small conference room tucked away in the basement of the hospital. The surgery clerkship director introduces himself, and demonstrates suturing, hand ties, and laparotomy technique using a neat simulator device for 45 minutes.

He then leads a 45-minute discussion on postoperative care and complications. “Everyday the attending wants to hear the vitals, labs, and I/O [input/output].” The first two or three days after a surgery, the stressed body will hold onto water. Beginning Day 3 or 4, the body will begin to mobilize fluid. If you don’t see this happen, you should start to worry.” Does anyone know when is the highest risk for postoperative MI? [blank stares.] “It’s day 3 or 4 if the patient does not mobilize fluid. The fluid overload basically causes congestive heart failure.” We learn about the five most common causes of postoperative fever [5 W’s pneumonic]: Wind (pneumonia/atelectasis), Water (UTI), Wound (infection), Walking (DVT), and Wonder Drugs.

General Surgery at our hospital is organized into four different services: (1) elective, (2) emergency, (3) trauma, and (4) pediatric. The speciality services, for example, cardiothoracic, urology, otolaryngology, orthopedics and vascular are seperate teams. If a trauma alert comes in from, e.g., a car accident, the trauma service responds by meeting EMS and patient in the trauma bay. If someone comes into the ED for an appendicitis, emergency will go to the consult and determine if they need emergent surgery or if they can wait for an elective surgery later in the week. Each team has one attending, one chief resident (PGY4 or PGY 5, postgraduate year 4, i.e., 4 years into residency), one mid-level (PGY 3 or 4), an intern with 1-3 medical students. The interns started only a month before us so they are also learning the ropes.

For the next three weeks I am assigned to the elective general surgery service along with classmate Christian Charlie. His fame among classmates was assured during the first year mock breast exam when he exclaimed, “Is this what breasts feel like?!?” During anatomy lab, he asked, “Is this where the clitoris is located?” (He was engaged when these questions were asked, then married at the end of Year 1.)

Orientation wraps up around 7:20 am for us to meet our team for a few minutes before the first case of the day. I meet my Chief as she downs one of her favorite La Colombe coffee cans in the Surgeons’ Lounge. The PGY3, Quiet Quincy, and intern, Bumbling Brad, walk in shortly after me. Quincy is pretty open about his situation. He originally wanted to do orthopedic surgery, but did not get into a residency program. Having failed to match, he did two preliminary years in general surgery at two different institutions before finally getting a “categorical match” in general surgery (starting as a third year) at our institution. The intern couple matched with his girlfriend who is doing plastic surgery.

[I asked Brad about the couple match process. “It was terrible. We didn’t get any of our top choices for her to do plastics while I did general surgery. Two spots makes up a large percentage of a residency’s slots.” He didn’t have to be married to his match partner? “You can couple match with anyone. You don’t even have to match to the same institution. You can couple match as friends, as same sex.” He joked that if you really detest someone, you could couple match and rank hospitals at opposite sides of the country.]

Charlie and I are assigned by the Chief Resident to one of the two attendings operating today. The Chief joins one attending while the PGY3 and intern manage the floor of post-operative patients. The PGY3 may occasionally scrub in if the chief declines the case, if the attending requests him/her or if the PGY3 has been following the patient for a takeback (additional surgery following a complication). The intern never scrubs in. Brad explains: “They want you to be begging for the OR.” The intern, PGY3, and I head off to the floor to manage post-operative patients while the chief and Charlie head to the OR for the first case, a lap sig col (laparoscopic sigmoid colectomy).

Around 9:00 am, I head down for my first case, a melanoma (skin cancer) excision from the left thigh. I introduce myself to the patient in the pre-op with the chief. I then go through the “OR tunnel,” turning around once to grab a hairnet after a nurse yelled, “Where’s your hair coverage?”. I walk in and the four individuals in the room look up briefly as they continue their preparation. Fortunately, Quiet Quincy told me to always introduce myself when walking in: “Hi, I am a third-year medical student who will be scrubbing in.” The circulator nurse responds, “Get your gloves.” I don’t know where they keep the gloves… I look around and see the cabinet. The goal to pick up two layers of gloves and get them on without anything non-sterile touching the outside of a glove. The packaging of the gloves is considered contaminated. Only what’s inside the package is guaranteed to be sterile.

I grab “8.5 under, 8 over” gloves (two pair) and walk over to the sterile field. With my contaminated hands, I peel back the glove pack so that Loudmouth Lilly, the surgical technologist (surg tech, aka scrub tech) can grab the gloves without touching the outside contaminated plastic covering.  

Lilly enjoys poking fun at my surgical oncologist attending and, especially, medical students. She grins and asks, “So how many gowns will we need with you?” (Assuming that I will “break the field” and have to re-scrub.) I nervously smile, “Just in case, I’ll grab another one.”

The patient is rolled in by a nurse and the anesthesiologist begins propofol [Editor: Michael Jackson’s first choice] and the inhaled anesthesia. I ask the circulator nurse to help me place the “foley” (foley catheter, a plastic tube placed into the urethra to empty the bladder). We both grab another pair of sterile gloves, just for this procedure, so that she can guide me through it. There are subtle tricks to make it easier, for example, pulling the plunger out of the lube syringe so you can anchor the foley tip. This stabilizes the foley so it stays in the sterile field until you are ready to insert it into the urethra. “Make sure you grasp the shaft firmly, once you place your hand down, it needs to stay there because it is no longer sterile.” I advance it until I see the flash of urine, retract it a little bit and blow up the balloon to anchor it in the bladder.

Quincy and I then go to scrub in just as the attending arrives. He is a new attending in his 40s who completed a surgical oncology fellowship after completing a general surgery residency. I take the chlorhexidine sponge and scrub for 10 minutes. After I rinse off, I struggle for a few seconds to push the OR doors open (a practiced butt maneuver; everything below the elbows must remain sterile), upon which the circulator nurse opens them for me.

The surg tech hands me a towel to dry my dripping hands. Lilly then opens the gown as I spread my arms into it. “Keep you hands inside.” The circulator nurse ties the gown from behind. I struggle to dip into my gloves as the surg tech opens them up. My fingers are in the wrong glove holes, but this can’t be fixed with a non-gloved hand so I need to wait until the other hand is gloved to try to fix the situation. “These gloves are way too big. Get 7.5/7.5”. Once the circulator nurse hands the new gloves to the surg tech, we reglove again. The surg tech whispers, “You’ll get better.” My second glove dive goes much more smoothly. I start walking towards the OR table. Lilly: “Hey, your card!” Oops. I need to finish gowning by wrapping the belt around. I hand the tech a card attached to one end of the belt. She holds it while I spin around thereby wrapping the belt around me. I then yank the belt end, detaching it from the card, and tie it in front. The nurses hoard these little cards. Why? “We write notes down on them. It’s kind of a bragging right if you get a bunch of them.” I take my place next to the PGY3 on the patient’s right with the attending, surgical tech, and her Mayo stand (stand over patient with accessible instruments) on the opposite side.

The pimping starts immediately. What are the different types of melanoma? Easy. Sarcastic Samantha gave me her copy of Surgical Recall. I keep this book in my white coat and reviewed the section and also UpToDate before the case. He realizes this, and changes the subject to soft tissue tumors. What is a sarcoma? I respond: “A neoplasm derived from mesoderm.” What kind of animals are they classically found in? I’m stumped, and take a wild guess. “I’m going to guess dogs.” He scolds me: “You need to answer confidently. It’s okay to be wrong, but be confident. You know more than you think, and you must be confident with patients. I would rather you be confident and wrong than be right and timid. Now is the time to be wrong when you have attendings and residents to correct you… And by the way, dog is the right answer. We’ve learned most of what we know about sarcomas from studying them in dogs.”

[Editor: A peek into the often-in-error-but-never-in-doubt factory!]

The pimping continues as we sterilize and drape the patient’s left thigh and inguinal (groin) region. I am tasked with taping the scrotum up to prevent contamination. How large an incision do we want on this melanoma? I respond, “Margins are based on the depth of the lesion. His lesion is under 1 mm and not ulcerated, so we need 1 cm margins.” He respond, “Okay, that’s not answering the question. Quincy, how will you make your incision?” He turns his attention to Quincy but summarizes every step in a confirmation of my presence. Quincy uses a sterile ruler to draw a 1 cm margin around the 1 cm circular lesion. He then creates a 9:3 cm ellipse to get good closure.” The attending asks me: “Do you know why we drew this ellipse?” “Is it easier to close? I mean, to make it easier to close.” He responds, “Yes, but why?” I don’t have a good explanation. “You need to stop us if you do not understand something. I assume you know it if you say nothing.” He moves on to continue the case. The questions cease once he watches the PGY3 make the incision and inject “Local” (lidocaine with .25% epi mixture in a syringe). Once they removed the entire ellipse down to the rectus femoris fascia, the attending marks the superior and lateral margin of the specimen with a long and short suture that I get to cut with a suture scissors. I use Army/Navy retractors to retract the skin as they mobilize the skin around the thigh. The attending asks Quincy, “How would you close this?” The PGY3 responds, “I would do a deep dermal with 2-0 vicryl, then a running subcutaneous with 4-0 vicryl and dermabond.” “Okay do that.” He turns his attention to me while he watches Quincy’s shaking hands at work.

He asks me, “How do we determine what lymph nodes to remove?” I respond, “We injected contrast for the PET/CT scan, and we inject dye that flows down the lymph node [I’m not sure when we injected the dye, perhaps with the local?]. “Yes, you must do a sentinel lymph node for any melanoma that is not in situ. Clearly this had 1 mm depth so we know it spread beyond the basement membrane. I’ll look for the black dye we injected in our lymph dissection, and we’ll use the scintillator to trace for nucleotide uptake. We’re good once we get all the nodes with a hit less than 1000.” We finish the lymph node dissection in about 30 minutes, and then the attending scrubs out while Quincy and I close — Quincy sutures, while I cut the knots. The first few cuts I am freaked out that I will ruin the knot by cutting too close, but I quickly learn to slide the suture scissors until I hit the knot. I get out of the OR at 5:30 pm after two more melanoma cases, each requiring a lymph node biopsy. We never get a lunch break.

Our team meets with the night team in the OR lounge for the evening handoff. We also divide up responsibility for checking on (“rounding on”) particular patients the next morning.

Tuesday is the first day that is typical of the rest of the rotation. The surgical oncologist (attending) starts his rounds at 6:30 am, requiring the Chief (resident) to start her rounds at 6:00 am. I have to see my patients before she starts and therefore wake up at 4:00 am, shower, and try to grab breakfast at Chick-Fil-A (discovery: they open at 6). I eat a few granola bars on the way to the OR locker rooms to change into hospital-provided scrubs. I arrive at the PCU (patient care unit) at 5:00 am and talk to the overnight nurse and night team intern about my two patients. No changes. I had not been present for either of my patients’ surgeries so I have to read the notes that are made confusing by Epic’s auto-populated SmartText templates (two pages of insignificant labs before the assessment and plan sections). 

I review the patient’s overnight vitals, I/O (input/output), and labs (at a minimum, CBC and CMP (complete metabolic panel) every night). Being unfamiliar with the most efficient summary screens (e.g., the “Rounding” tab), how to customize Results Review, and how to read I/O, I don’t get into the first patient’s room until 5:30 am.

My first patient: “Greg”, a 70-year-old s/p pancreaticoduodenectomy, commonly known as a Whipple procedure, for a biliary duct neoplasm on POD #6 (Postoperative Day 8, meaning he had the surgery on Wednesday of the preceding week). He has a pancreaticojejunal anastomosis leak, a common complication. This requires three peritoneal drains and NG tube decompression. The bilious drain output is increasing. His wife and two daughters are there (at 5:30!) and requesting a pathology report from the surgery. Is this a malignant tumor? I tell them the pathology report is still pending, but I will bring this up with the surgeon (same as this week’s attending). After I examine the patient, I write a progress note on the patient using a student SmartText template on Epic. Medical student notes require a co-signature from a resident, so the result is that the resident spends more time than if he or she did it to begin with. My classmate and I keep getting kicked off the limited number of computers by nurses and residents from other teams. I finish his note around 5:50, leaving little time to interview and document the second patient.

When the Chief arrives with her La Colombe coffee, the intern, resident, Charlie and I sign off our computer and follow her lead. Our pack of five travel the hospital and stop outside each of the ten patients on our service. The resident, intern or med student assigned to the patient presents the case in a 30-second-maximum presentation: one-sentence description of procedure; any highlights for vitals, labs, or overnight events; I/O including drain output; medications (pain control, dvt ppx (deep vein thrombosis  prophylaxis); and plan (diet advancement, tube removal, imaging required, etc.).

We get back to the nurses’ station a few minutes before the attending arrives at 6:30 am. We repeat the rounds with the attending. I mention the family requesting pathology results. He interrupts and instructs the whole team to never go over pathology reports with Whipple patients. “It is essential that I tell them what the pathology report says. We never discuss this while the patient is in the hospital. His goal right now is to get better, and only after will we begin that discussion.” The pathology report is released that afternoon: Adenocarcinoma of the biliary tract. A death sentence. Even if he gets out of the hospital, he is going to have to get non-curative chemotherapy.

The Surgeons’ Lounge is where surgeons get frustrations off their chest. I ask the Chief: Do you think my patient was a good candidate to get a Whipple? “Surgeons are by nature optimistic, especially <surgical oncologist>.” One surgeon joked: “I do not know where he finds these patients. They’re cockroaches, they just won’t die.” One attending chimed in: “One of his patients was so fat it took 160 Liters [of air] to insufflate. My god.” [insufflation: before laparoscopic surgery, the abdomen is punctured with a needle and pushed full of air until 12 or 15 mmHg. This allows better visibility when the other laparoscopic ports are inserted. Normal insufflation volume is 5-10 Liters.]

Quincy and I step out to refill our water bottles and he offers advice about the surgery rotation: “Much different criteria than internal medicine. Internal medicine wants to see how smart you are. That’s the time to show your intellect, to pontificate about the nitty-gritty details. Surgeons want to see you’re willing to put in the time and effort. You need to be competent, but hard work is a lot of what it takes to become a good surgeon.” He adds, “Also, make sure you know something about the patient before you go into the OR. You’ll get chewed out if you walk into a case and don’t know the patient name or HPI [History of Present Illness].”

After the nurse rolls Tuesday’s second patient in for a cholecystectomy (gallbladder removal), around 9:00 am, the anesthesiologist begins Propofol in a peripheral IV. I learn that if I want to do procedures, get to the OR early and make friends with the anesthesiologist. She guides me through placing a radial arterial catheter line (“A-line”). It takes me three sticks. “Good job, those are some calcified arteries.” (The Patient Care Unit (PCU) nurses that evening express concern about a large bruise on the wrist.)

The OR team can tell by the small details if you are competent or a newbie. Do you pull your arms all the way through when you spread your arms through the gown or stop at the white cuffs? Do you reflexively hand the belt card to spin around after your gown is on? Do you wait for the surg tech to acknowledge you or just open and hand your gloves to the surg tech? Do you grab the razor to shave the patient once he/she is under anesthesia? Do you get the Foley package or do you hover around the nurses until they grab it? The hardest part is learning the terms and abbreviations for different instruments and dressings. Once you master the smaller details, the surgeon will let you do more important things, such as closing the 5-port (smallest lap port incision) or suturing in a drainage tube.

The team discusses where to place the first port. Our attending: “What are the layers of the abdomen here, pointing to midline under the umbilicus [belly button]?” Me: “We are above the arcuate line, so from deep to superficial: Transversalis fascia, followed by the anterior and posterior aponeurosis.” The surgeon interrupts: “We’re midline…” Me: “Sorry, sorry, we have the linea alba, and the transversalis fascia.”

The Chief makes an incision and burrows down with her fingers. The attending watches and asks me, “What is the first step in this operation?” Me: “We need to insufflate the abdomen to 15 mmHg.” Silence, indicating a correct answer. The surg tech hands the Chief a trochar (rigid hollow tube with valves) to penetrate the fascia and enter the peritoneal cavity. I see the pop, they blow the balloon up and begin insufflating the abdomen with air. As the belly rises, the Chief slaps it.

The Chief: “Why do we slap the abdomen?” My guess: “To make sure it’s all the way in?” She is too polite to point out my error: “Yeah, we want to make sure we are pumping air into the peritoneal cavity, and not into the colon or small bowel.” Once insufflated to 15 mmHg, they remove the trochar, and place the laparoscope into the abdomen. I look on the television screen as the greater omentum appears followed by the small bowel and liver. They look down into the pelvis as they poke on the belly to place the next ports. They make two incisions and use blunt dissection (with their fingers or dissecting scissors) to create a path for the ports. The Chief hands me one of the port and trocars. “You do it.” I apply pressure, but the fascia is not giving. “Rotate it, it’s more of twist and shove than just a shove.” The transversalis fascia eventually gives and we have the ports placed.

Our overall goal: remove the gallbladder after gaining control of the cystic duct and artery. The attending grasps the gallbladder with “a Maryland” (forceps) while the Chief dissects the soft tissue attachments until the cystic artery and duct are two distinct structures. She applies 1 cm metal clips across the proximal and the distal end of what we believe is the artery (but was actually the duct). The Chief applies a clip to what we think is the duct and makes an incision with the scissors. The blood squirting into the abdomen tells us that we switched the artery and cystic duct. Attending: “Give me suction.” Now that the blood is being vacuumed out we can see and apply two clips to stop the bleeding. Fortunately this artery won’t be needed after the operation is complete. It takes the Chief six attempts to get a catheter into the duct so that we can inject contrast for an X-ray (fluoroscopy). The Chief and attending express frustration at the 5-minute wait for a tech. “They knew we would need them.” Her results shows two stones in the common bile duct (CBD). We call in a gastroenterologist for an ERCP (endoscopic retrograde cholangiopancreaticography). I hold the port while he drives the scope. We get to the duodenum quickly, but it takes 10 minutes to locate and cannulate (push tube out from the center of the scope) the Ampulla of Vater. We are looking for a pyramidal projection of mucosa where the liver and pancreatic juices drain into the duodenum for digestion. He finally finds it and injects saline to dislodge the stones. After injecting more contrast to confirm there that we got all of the stones, the GI leaves while the surgical team begins again. The Chief uses the Mother of All Staples to place 200 staples along two inches of ligaments attached to the liver. This is a two-minute procedure with the Ethicon rep in the room available to answer stapler questions. We use an in-abdomen bag-and-seal device for the gallbladder and yank it through the large endoscope port. I remove it from the plastic and the walls are slimy. When compressed I feel about five hard rocks.

The attending scrubs out, and allows the Chief and me to close the fascia and ports. Three more operations, no lunch break, and I get home at 7:30 pm. Pass out at 9:00 pm. Wake up at 4:45 am and do it again.

Jane is on her psychiatry rotation. She goes in from 8:30 am to 4:00 pm. She loves her Chief resident and attending. They bonded over the Harry Potter pin on her white coat. She interviews admitted psych patients while the attending observes.

In addition to AM rounding and cases, we eight students on the surgery rotation attend two lectures/round-table-discussions per week. This week is on appendicitis and diverticulitis by the surgery chairman. He’s a smiling portly fellow who wears bowties and pimps residents and students alike on the history  of surgery. Our class president, a huge suck-up, asks, “Isn’t it tough for a surgeon to have so much pressure. How do you cope?” The Chair asks everyone to introduce themselves and say what they’re interests are. Everyone says they are interested in surgery. I know they are not.

Friday morning we round 30 minutes earlier so that we can get to the M&M [Morbidity and Mortality] conference and resident lecture. Med students sit in the front with residents behind and attendings in the back. After M&M, an attending lectures on a surgical topic focusing on Boards. The attending selects an intern to answer questions. If he/she is unable to, the attending goes back a row to a PGY2, etc. Medical students are never called on.

Statistics for the week… Study: 0 hours. Sleep: 5 hours/night; Fun: 1 night. Example fun: Burger and beers at 5:00 pm. Mischievous Mary is the first to complete her 100-beer list. We joined in for the celebration, but leave at 7:00 pm for my 8:30 pm bedtime.

The rest of the book: http://fifthchance.com/MedicalSchool2020