Long Day of Surgery

Well, another surgery day is at an end. I was first-assist for a cholecystectomy and a thoracotomy plus decortication. The cholecystectomy was fine, went about as expected - and I sutured up two of the short incisions and they looked quite nice. The thoracotomy is where it starts getting interesting - it was on this 22 year old obese autistic individual, very obese. We had to go through 4 or 5 inches of fat to get to his ribcage where we had previously inserted a chest tube to drain pleural effusion. The guy had a really bad pneumonia infection and it had caused empyema, so we needed to go in, break a rib, spread his rib cage a bit, and detach as much of the pus-covered fibrinous exudate as we could - it was really remarkable how much there was. Imagine peeling really glued on labels off a glass beer bottle, except instead of glass it's lung tissue and the label is dense clotted blood, pus, exudate, and fibrin material. It took a total of 2 hours to do the surgery.

After that I observed a cholecystectomy, but this was kind of an odd case because the woman had a standalone piece of liver, about 2 inches by 1 inch by 0.5 inches, living by itself on her gallbladder. It was really weird, it had it's own blood supply and everything. At any rate, same procedure took place - removed the gallbladder along with that tiny chunk of free-living liver, and stitched the woman up. She took a half hour to come out of anesthesia and even then she was too weak to do much so they decided to intubate and let her sleep and recover overnight.

In other news, my car needed to be repaired, battery/alternator trouble and the cost is gonna be about $2,000 - really painful to think about. At least I have loan money for this sort of thing - unfortunately they still haven't disbursed the majority of my loan money because there is some problem with my stafford loans over at the main university headquarters on the east coast and they are waiting to hear back from them. If I don't hear anything tomorrow, I'll bug them again.

Also, I contacted an infectious disease specialist who works with AIDS patients and he told me to email him so we could set up the rotation - I haven't heard back yet, but hopefully tonight or tomorrow he will respond and I'll know if/when my infectious disease rotation will be. I'd really like to do that, we shall see.

Starting the Last Week

Well, after a nice weekend with friends, boyfriend and family, time to get back to work. Today I helped drain a cyst, and dress a wound, as well as finishing up the suturing on a VAP placement. It worked out pretty well, the suturing looked good, and the doctor seemed to be in a decent mood. Got out at a decent time, but ended up having to take the car into the shop. I have a rental at the moment, which is kind of a hassle, but at least it's getting stuff fixed and I'm getting a detail, so it should be nice and pretty when it gets back.

Later this week there are a few other surgeries, nothing particularly radical, but it looks like a nice load, nothing too stressful. On Thursday a mutual friend is coming to stay with me and my boyfriend for a bit and there should be some nice social fun going on this coming weekend. Next week on Monday I start my Family Medicine rotation at Kaiser Permanente - here's hoping it works out all right.

Connecting with Patients

Despite this being a surgery rotation, where you spend most of your time cutting into unconscious people, I'm getting to connect with quite a few patients in unexpected ways.

First off, yesterday during clinic hours I was interviewing a 34 year old Hispanic woman and getting information about her concerns about a benign lump in her breast. However, as we were talking about her allergies (raw onions) and I asked if anything else made her throat swell up like that, she said that the last couple weeks her throat has felt more swollen - like there was more fullness. She also felt like the back of her tongue was swelling more. Considering her race, age, gender, and that symptom, I thought I'd ask her a little bit about thyroid problems - turned out she was having cold intolerance lately, extreme fatigue, difficulty sleeping, palpitations/chest pain/anxiety, and her father and aunt on her father's side both have thyroid disorders. I asked her if she had talked to her primary care physician about this and she said no, that her PCP doesn't really talk to her about that much - that she's really rushed. I told her that I was thinking it could be a thyroid problem, that if I were her doctor I would want to check it out but that I would run it by the surgeon and see if he was willing to look into that. I mentioned it to the surgeon, as humbly as possible since I am terrified of sounding like a know-it-all medstudent who tries to diagnose a million things, and he immediately said "Sure, we can order a thyroid panel."

I don't know if it was the fact that I had actually made a physician-like decision in a patient's health, was suddenly afraid that I might be wrong or out of my mind, or just that the surgeon had actually taken my concerns seriously - but I was baffled for a moment. Of course, it could be that she is just tired from having two young children, maybe she is anxious from having a breast lump, maybe the chest pain is related to muscle pain in the breast, maybe the throat swelling is just an incidental finding, or maybe her cold intolerance is just in her head but it was exciting to actually have a tiny feeling of what it is like to be a physician.

In another situation, today after we finished what we thought was the last surgery for the day, it turned out that we were going to see an appendectomy patient. There was a 9 year old girl in the emergency department with acute appendicitis. Before I knew anything about the case, the surgeon told me to go to the ED to check out the patient and wait for him there. When I got there, I found an adorable teary eyed 9-year old Hispanic girl and her father, grandmother and uncle. Her father spoke pretty fluent English, but her grandmother and uncle both did not. Since they seemed to understand me when I spoke Spanish, I carried on a conversation with them, telling them a little bit about the surgery, that she would be put to sleep for it, that I would be there in the OR with her. The grandmother was keeping it together pretty well but when the little girl started to cry she started crying too, saying to me (in Spanish) "Since we cannot be there, can you please speak to her on the way to the room and in the room until she falls asleep so she isn't so afraid? Since you speak Spanish..." I almost started tearing up there and told her I would.

Since I was taking on the task of guiding this little girl to the OR, I took a moment there to talk to her a little, tried to get her mind off the impending operation by asking about brothers or sisters, about pets or anything. I remembered a story about Madeleine and how she actually had her appendix out and asked her if she knew the story and she said she did so we talked about that a little bit before the Anesthesiologist came. He was very nice as well and spoke very broken Spanish so that helped too.

When we got everything in the OR set up, we got the laparoscopic tools set up and the surgeon let me staple/cut the appendix out, as well as bag it in the collapse-able bag and pull it out through one of the tubes. He was getting a little antsy to get out of the OR near the end, probably since it was an unplanned surgery, so it was a little nerve-wracking but my fellow PA student reassured me that I did a great job and that it was really exciting to watch. Quite a fun filled past couple of days. We were going to discuss how I have been doing on this rotation, but he said we could do it tomorrow, so tomorrow morning I'm to remind him about that. No clue what he will say, but hopefully it'll be good. I'm glad my Spanish-speaking skills are coming in useful these days - now that I think of it, one of the other Spanish-speaking patients' daughter (middle aged) who was translating for me in the room on a clinic day complimented my Spanish skills in front of the surgeon. I wonder if he sent me to the room early today so that I could talk to the family with that in mind.

Either way, tomorrow is another clinic day, and hopefully constructive feedback from him about my performance, and maybe that woman got her thyroid function panel done for me to check on it. It'd be exciting if I successfully diagnosed someone with something that other doctors hadn't identified yet.

Colectomies Galore

One of the days last week that I was shadowing surgery had two Colectomies in a row, in which a portion of large intestine needed to be removed and reconnected (anastamosed). It was interesting because I got to see two very different approaches to anastamosis.

The first case was a patient who had a very large volvulus, or twist, in the ascending colon. A volvulus can occur in the ascending or descending colon, because those portions are fixed at the hepatic and splenic flexures (respectively) and the lower portion is hanging freely, with the potential to get twisted about itself. The volvulus was pretty big, about a foot long and 1/3 of a foot in diameter. After it was clipped off on both sides and removed, there were two pieces of colon that needed to be anastamosed and those were connected the same way I mentioned in the previous entry.

The second case was a patient who had had an emergent colectomy and colostomy bag put in, without a reanastamosis, so in this case they were going back in to finish up the colectomy, and anastamose the pieces to the rectum. The difference in this case is there is not enough room by the rectum for a surgeon to work very easily with his hands and clips, so instead they did the majority of the procedure laparoscopically. Once they had prepared the colon end that they wished to connect to the rectum, they inserted a circular disk with a metal male port perpendicularly. This produced an end of intestine that had a circular disk within the very end, and through the center (where the lumen would be) the male prong was sticking out. They then took another circular disk, except with a female port, and pushed it up the rectum to the point that they wished to create the new lumen and pushed the prong through the wall of the intestine at that point. They laparoscopically connected the two ports, producing a metal connecting rod between the two disks. The metal connector then approximated the two disks, to the point that there was a seal between the two parts of the intestine. The disks then cauterized the area and the entire apparatus was removed, leaving in its place a new lumen created between the sigmoid and the rectum for bowel contents to bypass the area that had been removed. I had never heard of this type of procedure before, so I was kind of clueless as to what was going on for the first half hour of the procedure. Mental note: Find a page later to link to procedures so that it's easier to understand what I am describing...

Well, more surgery clinic appointments today - I should also be meeting the new PA student from Touro who will be sharing my preceptor for the rest of my rotation.

Loooong Day

Well today was extremely long. Kinda surprised it didn't FEEL longer. Got to the clinic at 8:30am, expecting a short clinic day getting out around 12:30 or 1:00 - instead, the doctor was about 20 minutes late so we had a lot of catch up most of the day, and I didn't have the PA student with me so I had more patients to see than usual. I also did some injections and assisted with a skin nodule extraction - outpatient minor surgery at the clinic. Mostly stressful just because I wasn't sure how to do any of it, not that it was difficult. By the time the patients were gone it was probably 1:30, and I was trying to finish up my SOAP notes. In the meantime, the doctor was trying to get a bed in the OR for a patient with an ulceration in his intestines and was having trouble. Eventually it was scheduled for 3:00 PM, so we drove over to the other hospital around 2:15pm, I got dressed, checked the OR list of procedures to see how on time they were, and then rushed to the physician lounge to get something to eat or drink. Found an energy drink, elected to use the zero carb one, downed that while I waited for 3:00 to roll around, around 4:00 maybe the surgery started.

Today we cut into the first patient's abdomen, and pulled the intestines out of the abdomen and onto the patient's belly so we could look for any perforations that were causing the patient to lose fluid into her peritoneal space. This consisted of cutting away the connective tissue holding the intestines coiled and going through it at length to find stuff. It really looked like an evisceration. Got to see a bunch of new anatomy, and it was an interesting exploration - didn't find a perforation and the fluid was all clear, so it was probably from the pleural space. After that, the doctor had to do ANOTHER one, except this time the guy almost certainly had a perforation in his gut somewhere - he was in a lot of pain. We did the same thing as for the first patient, except we found the hole in the guy's sigmoid colon and the fluid in his abdomen was brownish. Yeah, pleasant. Anyhow, I got to see how you cut out a segment of colon and reconnect it. There are a lot of specialty clipping tools and ways of doing it that I hadn't thought of - it was very interesting. I mean, when you think about it, how do you get a piece of large intestine out and connect the tubes without spilling fecal matter all over the place? With lots of nifty tools and tricks, that's how.

Anyway, got through all that, by the time all this was over and the patient was back in his hospital gurney, it was 8:00pm. SO..... basically a 12 hour day. A few pluses: Saw some new procedures, assisted in new procedures, talked more with the surgeon, and people (including the surgeon) were addressing me by name for the first time. Guess they're starting to get more used to me.

As an aside, for anyone who has played RPGs, I started feeling like a total NPC today - following him around, if I lingered and he got away from me a bit I would jog to catch up, I'd be stuck in doorways or be hindering things (but honestly mostly helpful). When I got that thought in my head it was hard to not laugh. Another day of surgeries tomorrow, hopefully just the three that I know are scheduled. Time to take some ibuprofen for my aching feet - I didn't know we'd have surgery so I stayed in my dress shoes all day and my feet are KILLING me!

General Surgery Rotation - Week 2

So far the week is going well. Monday we started out with some clinic cases, and then we headed to do a thoracic surgery - removal of the lower left lobe of the guy's lung. It was pretty interesting - had to break open the ribs, and then slowly remove the lung - it was pretty involved. Amazing that lungs, which seem so delicate when you read about them and such, can handle a person shoving them around with their hand. I got to feel the diaphragm, descending aorta, lung tissue, saw the heart beating in the guy's chest - feel pretty privileged to be able to partake in things of that sort. Few people can say they've had their hands inside a living person's rib cage.

Today went well also, had a few surgeries, this was the last day the PA student was there, so for the next few days it'll just be me and the surgeon until the next PA student arrives. I assisted in a neck lumpectomy and a breast lumpectomy - it's amazing how vascularized fat is. With the neck fat there were sprays coming out here and there - with the breast tissue I've come to expect that. Had to find the lymph node, and I did an essentially complete final suture - the surgeon actually said it looked good, so that felt really good - all I really want is to not look like a complete idiot. Anyhow, tomorrow is more clinic patients - maybe I will be done by 1:00 or 1:30pm - that would be nice, since today I was done at 4:30, and I want to get more of my studying done.

In other news, my boyfriend and I have our 5 year anniversary coming up - we'll be dining somewhere in San Francisco - should be nice.

Day 3 and 4 General Surgery

Yesterday I went in and took histories most of the morning, tried taking a thorough history, then tried to make them more focused. My notes are looking more proper, I think it helps that we didn't have any minor procedures that day, which are not quite surgery, not quite a normal visit, so those are a little challenging to document. Starting to talk more to the surgeon, which is good. He's warming up to me, I suppose. His 1:00pm surgery ended up getting pushed to 3:30pm, so me, the surgeon and the other student mostly sat in the physician lounge chatting for a while. It was nice, getting a bit more comfortable. Then we went to the surgery, it was an exploratory laparoscopy, which was interesting to observe. Ended up extracting an ovary and ovarian cyst (benign).

Today he had a hernia repair in the morning, during which I assisted. I got a few pimping-type questions, which was fun, and the anesthesiologist joined in as well and he was impressed that I seemed to know stuff - "It's refreshing having bright students come through." I don't know if it helps that I'm a girl, but at any rate, it was nice to get a little positive feedback during the experience. I also lucked out that the questions I got were rather infectious-disease related, which of course is one of my main interests. I still got to make the first incision on this, and also tied off the last suture for the mesh.

The next surgery I observed, it was a fistulotomy repair. The scrub nurse looked like Dr. Chase from House (teehee). After that we went to a different hospital and I assisted with a VAP insertion (Venous Access Port), in which we insert a tube into a vein and there is a subdermal port attached to it which is used to make it easier to administer chemotherapy and such. So, my part in it was identifying the trajectory of vein via syringe needle, then inserting a guide wire about 2-feet through the jugular vein, guiding a plastic tube around the guide wire, and then removing stuff after we got the port connected. I also got to do the subcutaneous suturing. Final surgery was observing another hernia repair and that's the end of the day. We were expecting to do a thoracotomy, but that guy got postponed to another day. I also got to watch a chest tube insertion on a guy with pneumothorax and lung cancer. Interesting, for sure.

Oddly enough, I find that doing the surgeries themselves is a lot more interesting than meeting with patients and writing SOAP notes after the encounters. I guess because it feels like a lot of busy work and they don't feel like regular patients since they are all referrals for surgery it feels like a pointless exercise. Also, in surgery you aren't dealing with people, you're just dealing with their flesh - it's like a mini-crafts project almost. You have cutting, pasting (I guess cautery can count as pasting - or cooking, haha), sewing, organizing, sculpting... I duno. It's interesting. I still highly doubt I would go into surgery, considering the years of training, the unpredictable hours, and constant standing and high risk of lawsuits, but this rotation is turning out to be a lot better than I was expecting.