Philip Greenspun’s Weblog

“The first week was pure adrenaline. I never felt tired. This week I’m crashing hard,” comments Surgeon Sara, a classmate on the emergency surgery service, as we head up in our scrubs to the PCU at 4:45 am. I’ve learned that I need more time so I wake up 15 minutes earlier at 3:45 am. We both reminisce how we should have studied basic postoperative recovery timeline (e.g., Enhanced recovery after surgery (ERAS) protocol, pain medication regimens, anxiety meds, etc.). 

Several of the attendings are on vacation so we have a light caseload for elective (non-orthopedic) surgery with the exception of the surgical oncologist’s cases. The Chief is very excited about “her Whipple” on Thursday. I let my classmate Charlie scrub in on some more melanoma cases while I try to get in on some cases on other services. There are always ample orthopedic cases going on all hours of the day (including Saturdays), so my goal is to find a joint replacement.

The first step is to check Epic for the “Status Board” of scheduled surgeries. There are no private desks or offices. Using a personal device is challenging due to VPN requirements for accessing the hospital’s Epic system. I take a rolling cart containing a Windows PC, which will connect via WiFi and Citrix, to the end of a deserted hallway. I find a shoulder replacement that looks interesting and watch a couple of videos in prep while consuming Cheez-Its and granola bars at 10:00 am.

Second step is locating the attending to ask if I can scrub in. Epic shows his name, but not a photo. His university profile page contains a photo, but these images are usually 10-20 years old. There are six attendings in the OR lounge, identified by badges, and I find him on my third attempt. “Of course, I’ll see you there in ten minutes.”

We’re doing a total shoulder replacement. I help retract as the surgeon hammers in the prosthetic joint parts. When finished, the surgeon steps out to begin another scheduled case and the PA allows me to close the incision sites under her guidance. I ask where I can get trauma shears, the most coveted item for medical students hoping to be useful during rounds and trauma alerts. They can be used for cutting clothes off a trauma patient, during dressing changes, and for chest tube removal.”Stay here” She disappears for 30 seconds and returns with a brand new pair.

I get out of this case and a follow-on shoulder arthroscopy (minimally invasive procedure using endoscopy to evaluate and clean out a joint) at 12:30 pm and find my team in the OR lounge. The cases are finished, and they are planning to check in with the intern before the Chief heads out for the day. I check the status board and notice an organ procurement procedure is posted. I ask my Chief if I can see that. “Yeah, they might already be finished.” As we are in the elevator, Christian Charlie mentions, “That’s awesome you’ll be watching an organ harvest. Good luck!” The Chief responds: “We don’t use the term harvest; it’s ‘organ procurement’. But yeah, they are surprisingly quick, in and out in 30 minutes, but you can’t beat the anatomy experience.” I head down to OR 10.

When I arrive, there are 10 people sitting on the floor outside the OR. The donor is 35 years old, suffered a car crash a week earlier, was declared brain-dead yesterday and had care withdrawn, thus initiating the donation cycle. Three different transplant programs have arrived — a heart, a lung, and a liver/kidney team. They’re waiting for final approval from the hospital’s legal department while the donor is kept perfused by the anesthesiologist, the one remaining member of our hospital’s team. The patient checked the organ donor box for his driver’s license years earlier, but the organ donor program (typically a contracted company for the state) also sought and received written consent from his wife, which initiated the transplant program (the care team never brings up the possibility of organ donation with a family). Two hours, the wife withdrew her consent and requested a delay for reasons that are unknown to us.

The heart team includes an attending, a cardiothoracic surgery fellow, and resident. I take them to the cardiology reading room so they can review the TEE (transesophageal echocardiogram) images to confirm an acceptable heart. Everyone agrees it is a strong heart. When we return, there is no resolution on the consent issue. I check back in with my team still in the OR lounge. Christian Charlie went home around 2:00 pm, and the Chief is packing up. I head back to the OR and take a seat with the transplant teams.

The surg tech explains that he is on call for blocks up to 72 hours, and has to be at his local airport within one hour of a call to board a business jet.

[Editor: Our Boston-area organ program has a Cessna CJ4 and the pilots work week-on/week-off shifts.]

The state-authorized transplant coordinator finally gets an update. The wife wants to cancel the donation. This ignites a tense discussion among teams and four institutions legal teams (our hospital’s, plus lawyers from each of the three hospitals that have sent transplant teams). The attending from the lung team wants to go ahead; the other two are leaning towards declining. A life-or-death situation calls for people to drawn on all of their philosophy, moral background, and legal training: “I’ll decline, if you’ll decline,” says the liver/kidney attending to the heart surgeon.

The lung team calls home to see if they can use the other organs, but the transplant coordinator begins calling further down the list. “We have to continue going down the list as long as my program and legal say its a go.”

“My responsibility is to my patients and their families back home,” says the lung surgeon in an Old World accent and a tone that would earn him a role in the next sequel to Silence of the Lambs. The heart attending: “If the wife starts talking to the press, this will set back transplant medicine a decade. I know we might have legal ground, but as a doctor if you are not comfortable with something you always have the right to decline.” The perfusionist on the lung team: “This doesn’t seem right.”

I leave at 7:00 pm and learn the next day that the organ procurement occurred at 3:00 am. Hannibal Lecter got his lung and two new teams jetted in overnight for the two two. Ultimately the widow had agreed to the procurement.

Thursday is the big day. The Whipple, a 6-11-hour procedure to remove a bile duct tumor (see Week 1). We are the first and only case scheduled for our OR. Only one student can be officially scrubbed in at once, so Christian Charlie and I agree to alternating two-hour shifts. We finish rounding at 6:45 am and head down to Pre-op to introduce ourselves to the patient. We help move the patient from her stretcher onto the OR bed, and the CRNA (Certified Registered Nurse Anesthetist) lets me intubate the patient!

Charlie scrubs in first. I’m not officially scrubbed in, but watch from a stack of three step stools behind the drapes at the head of the bed.

The chief begins with a large midline incision from one inch below the xiphoid  to one inch above the pubis. Christian Charlie helps suction and retract. Once the parietal peritoneum is opened, the Chief uses clips and the Bovie to dissect the lesser omentum of the stomach. The attending questions Charlie: “What vessels are we cutting?” (short gastrics) and “What space are going into when we cut this omentum?” (lesser sac). Charlie won’t admit ignorance: “It’s something in the abdomen.” From my perch I ask, “Why don’t we have to remove the fundus if we take the short gastrics [that are supplying the fundus with blood]?” The attending explains, “The stomach is one of the most collateralized organs in the body. You can take a few vessel groups and it will still be happy.”

After about 30 minutes, they’ve gone too deep for me to see anything so I head off to my secret alcove and find the computer still there on its rolling cart. I watch YouTube videos of the Whipple procedure and read UpToDate as I eat Cheez-Its.

Charlie and I swap for the rest of the day. The most exciting part was when we were dissecting the common bile duct off from the portal vein. The tumor had spread into the adventitia of the portal vein requiring extreme care. “Careful, careful!” exclaimed the attending as he takes control from the Chief. The team will work until 11:30 pm, but Charlie and I have to leave for a required “learning environment” session at the medical school hosted by the Chief Diversity Officer. Charlie is unhappy about missing the rest of the operation and as we walk over, we encounter Ambitious Al, who had to scrub out of an exciting rib plating on a car accident victim (“MVC” for “motor vehicle crash”). “They might have let me do the chest tube.”

We are 10 minutes late, but people are still filing in. We watch the same PowerPoint that we’ve seen four times previously in two years about types of reportable mistreatment. The Chief Diversity Office maintained an excited high-energy tone through slides defining harassment and avenues for reporting it, but many students took advantage of this break to check Facebook and Amazon from their laptops. Those on surgery rotations whispered about what they were missing. Last year’s 45-minute lecture has been extended to 2 hours and 15 minutes total, including a 1.5-hour block for 8 students to go through scenarios with a dean.

We get a one-paragraph description of a case and each student is required to say something before we move on to the next one. A sample of the 11 cases…

Case 1: A surgeon hits a student’s hand that is holding an instrument and yells, “Don’t do that.” The student begins to cry. Our Chief Diversity Officer opens: “The attending should never hit a student. Period.” Lanky Luke: “We don’t know the full story. Maybe the student was about to do something really bad on the patient, and it was a light tap, saying don’t do that.” Canadian Camy: “That is still inappropriate. It makes you feel very uncomfortable, especially if it is a male hitting a female.”

Case 2: The chair of the department notices a female medical student studying in the library. The chair begins asking questions about the subject, which she can’t answer. He continues to press, until she begins to cry. Class President: “There is a clear distinction between teaching versus emotional distress. There is no reason to push someone until embarrassment and mental distress.” Type-A Anita: “Sounds like a douchebag old white male getting off on a powertrip.” Chief Diversity Officer: “I love that! I’ll have to use that with next year’s group.”

Case 3: Two males and two females are on an away rotation. The two males become good friends with the residents while playing basketball after work. They start to go on “boys night out”. The two female feel like they are getting less OR time and less teaching time. Is this inappropriate? Type-A Anita: “Everyone should be given the same opportunities.” Chief Diversity Officer: “I think there is a win-win scenario here. The women should ask to meet up with the team for drinks after basketball so everyone gets to know each other.” [Editor: What if the two females are Muslim and don’t drink?]

We get out at 7:30 pm and start at 4:30 am Friday morning for more of the same.

Christian Charlie and I begin a 24-hour call shift at 6:00 am on Saturday. We join the Chief, Quiet Quincy (PGY 3), and Prego Patricia (an intern

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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

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