I am excited to start a surgical elective with my favorite retired trauma surgeon who led our first-year anatomy lab. Jane, Buff Bri, Southern Steve, Lanky Luke,, and myself each choose various surgical techniques to work on for the next two weeks. We have three untouched cadavers to work on.
We meet at a local coffee shop that is walking distance from the anatomy lab. Jane and I bring our new puppy for socialization! The trauma surgeon spends the initial 30 minutes giving us puppy advice from her experience training service animals. We each identify various surgical techniques to focus on. Jane, Luke, Steve and myself will use our time with the cadavers to focus on abdominal exposures and neck dissection. Bri, applying to neurosurgery, will perform an external ventricular drain (EVD) and various craniectomies for aneurysm exposures.
The next day, we meet at 9:00 am in the anatomy lab. We focus on placement of thoracostomy tubes (“chest tubes”). Our professor describes the triangle of safety bordered by the latissimus dorsi, pectoralis major, and the imaginary horizontal nipple line. We pair up. I extend the cadaver’s arm to open up the rib spaces. It’s no small feat due to the rigidity of the joints. Jane makes a small incision and then uses Metzenbaum (“Metz”) scissors to dissect down through the subcutaneous fat and through the intercostal muscles. “The surest way to get kicked out of the OR is to use Metz to cut suture. Metz are incredibly expensive and ruined by cutting suture.” Jane then takes a Kelly clamp and tries to push through the last centimeter of muscle and pleural lining. “Heave!” exclaims the trauma surgeon. “Push harder!” With an audible pop, Jane shoves the instrument into the pleural cavity. “Good! It’s a lot more force than you realize.” She then does a finger sweep. “I feel the lung!” She then smoothly places the chest tube. “Some people will say to orient the chest tube towards the apex for a pneumothorax and towards the base for an effusion. The apex always works.”
My turn. Jane holds the arm up while I make an incision. “You’re really digging deep!” the trauma surgeon comments. “You have just made the most common mistake of interns and ED docs. Don’t tunnel up along the chest wall to the axilla; go straight to the ribs.” Once I pop into the pleural cavity, I struggle to advance the chest tube, unable to push through the resistance. The trauma surgeon takes a feel sweeping her finger in the cavity. “Wow, feel all the adhesions. This patient must have had a bad pneumonia causing all this scarring of the lung to the pleura.” She adds, “This is how you really hurt a patient. If you just blindly shove the tube in, you can tear the lung causing bleeding or a bronchopleural fistula [connection between lung airway and outside]. Always, always feel for adhesions with the finger thoracostomy before you insert the tube.”
Thursday morning we meet at a local coffee shop to discuss rectal bleeding and peptic ulcer disease. The nearby coffee drinkers must have loved our discussion on the significance of the “sweet smelling black loose melena” versus “red-streaked formed stool”. Trauma surgeon: “Blood is a spectacular cathartic.” Bri: “If a patient is bleeding out, they are shitting out.” The trauma surgeon chuckles, “Exactly.”
Statistics for the week… Study: 2 hours. Jane and I watch a section of Acland’s Video Atlas of Human Anatomy over wine to prepare for next week. Sleep: 7 hours/night; Fun: 2 nights. Example fun: weekend AirBNB with Jane’s family, including a 6-month-old nephew. There would be less depression and anxiety in this country if everyone held an infant once a year.
[Editor: It might be best to hold someone else’s infant. “Parenthood and Happiness: a Review of Folk Theories Versus Empirical Evidence” (Hansen 2012; Social Indicators Research) says “people tend to believe that parenthood is central to a meaningful and fulfilling life, and that the lives of childless people are emptier, less rewarding, and lonelier, than the lives of parents. Most cross-sectional and longitudinal evidence suggest, however, that people are better off without having children. It is mainly children living at home that interfere with well-being…”]
The rest of the book: http://fifthchance.com/MedicalSchool2020