Medical School 2020, Year 4, Week 28 (Advanced Surgery, week 2)

Still with the cadavers… this week we focus on neck procedures. Budding neurosurgeon Bri will focus on the anterior approach to a cervical fusion (called an ACDF, anterior cervical discectomy and fusion), while the rest of us focus on the technique for a tracheostomy (“trach”) and thyroidectomy. Bri passes out expired tracheostomy kits including a percutaneous (“perc”) trach kit.

Our trauma surgeon professor describes the scene: “It is an eerie night on call. At 2:00 am, an airway alert is sent out. It’s only you there. You arrive in a crowded room with a blue patient and the anesthesiologist puts the laryngoscope in for the third time. He isn’t able to intubate. The patient’s heart rate is dropping.” She pauses.  “The patient is about to code. He needs an airway. What do you do?” With blank stares, she gives us the answer: “Well first, you need God on your side so pray the patient is not obese. After that, all you need is an endotracheal tube and a scalpel.”

“Everyone palpate landmarks on each other. Feel the cricoid cartilage.” (The horizontal prominence below the Adam’s apple.) Our professor explains that there are multiple paths forward. “You have to choose one. Know what you are most comfortable with performing.” There are three main options: a cricothyroidotomy (tube inserted into the larynx through the cricothyroid membrane); an open tracheostomy (cut down on the trachea to insert a tube); a percutaneous tracheostomy (tube inserted into the trachea through a needle stick with serial dilations). “A cricothyroidotomy is a temporary procedure. It will need to be revised to a tracheostomy to prevent damage to the larynx over weeks, but in this scenario nothing matters if the patient can’t oxygenate.” She continues, “Old surgeons trained in an age of open trachs. Most trainees are more comfortable performing perc trachs.”  

We head to the anatomy lab to practice performing a tracheostomy with the expired kits. “My advice when you arrive at your new hospital is grab a kit for each procedure and open it up. An experienced surgeon will struggle performing a procedure if there is a new kit.”

For the next three days, we focus on the technical aspects of a thyroidectomy. The general surgery residents join us for this. The fourth and fifth year residents help walk the interns and medical students through removing one lobe of the thyroid. “Stay as close as you can to the thyroid when you divide blood vessels.” A third year chimes in, “Thyroids scare me. One small misstep and you’ll hit the recurrent laryngeal nerve.”

We finish the rotation at a coffee shop that is a five-minute walk from the anatomy lab. The trauma surgeon recounts her experience on a civilian medical response team, which was deployed after Hurricane Katrina in New Orleans and following the 2010 earthquake in Haiti. “Contrary to popular belief, a vast majority of the patients we treat are not injured from the disaster. Instead, we care for typical medical emergencies, for example, heart attacks, wound infections, appendicitis, and preterm labor, in a suddenly austere environment,” she explains. “In Haiti, a single generator powered the makeshift intensive care unit and operating room. Of course this went down for about 24 hours. Our team bagged a preterm intubated baby when the ventilator backup power stopped. She survived!”

Bri comments that his sister is in the Army Reserves as a nurse. She was recently mobilized, but the entire unit is staying in a hotel waiting for orders. This does not surprise the trauma surgeon. “Yeah, my team was sent to Iowa for two weeks waiting for orders only to be sent home eventually without having done anything.”

Statistics for the week… Study: 0 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Burgers and beers with Lanky Luke and Sarcastic Samantha. Samantha deliberates on the pros and cons of switching jobs. She is exhausted from stringing along patients who need consults with specialists who hide in hopes that someone on the next shift will take the patient instead. “I looked at the academic hospital, but they pay $30,000 less.” Luke: “I strongly recommend against a pay cut.”

The rest of the book: