Friday, August 16, 2013

Surgery

My surgery rotation was exciting, intense, and fun with a lot of long hours. I was standing across the patient opposite the surgeon for all procedures and my name was on all the records as the first assistant. There are only two general surgeons at this hospital which covers this city as well as four or five other outlying smaller towns. This means that all ER trauma and abdomen pain patients, as well as all ICU and ward chest tubes, central lines, and port-a-cath placements, day or night, were seen by two people...with me in tow.

Additionally, each day part of a surgeon's schedule includes 'rounds' which involves checking in on patients, reviewing the chart, hearing a nurses report, evaluating fluid status, and making recommendations that move a patient closer to discharge. Important milestones that we would look for are a patient's ability to keep fluids and then solids down without nausea, the ability to control pain without IV pain medication, and an incision healing cleanly.

It was not uncommon for me to arrive at work at seven am and stay doing procedures and rounds until seven or eight pm and then be given a three hour assignment to have ready for the next day. Preparation for the next day would include familiarizing with the technique and relevant anatomy of the procedures involved. For most of my time there we had at least ten patients to round on and for one week we had eighteen and each patient took 20-30 minutes of attention.

I never felt light-headed or the desire to faint, but there were two times that I was very close to vomiting. The first episode was during an external hemorrhoidectomy in a 93 year-old male. Right when we were ready to begin cutting, he has a bowel movement that lasted about ten minutes. I'll spare you the description, but it required us to resterilize everything and left a horrible smell in the OR. I had to spend a few minutes rocking back and forth in the corner with all the nurses and anesthesiologist laughing at me. The second episode happened when I was given the responsibility to sterilize the abdomen which requires cleaning out the belly button. This happened to be an obese patient with a deep belly button that I'm convinced had never been cleaned. I stuck my finger in there and pulled out a hard something with 1.5 cm diameter as well as hundreds of smaller sand-like granules. Something about the situation caught me flatfooted and I wanted to vomit, but didn't. Again, the nurses all laughed at me. They find people with weak stomachs amusing.

The surgeons I worked with thankfully did not meet the stereotype. They were considerate, patient, and congenial with varying levels of didactic fervor based on how pressed for time we were. The anesthetists were the grouchy ones and they felt it was their personal duty to try to make my life miserable. 

Overall, I enjoyed my surgery rotation. I loved the excitement, the variability, and most of the people I worked with. I admit I had a rose-colored window into the surgery world because I was not required to come in for the three am appendectomies and other surgical emergencies. The hours that surgeons are required to put in and be operationally functional astounded me. At one point during a seventy-two hour stretch while one of the surgeons was on vacation the remaining surgeon was called in every night and was operating with only 1-2 hours of sleep per night...and they told me the five year residency was even worse. I think if I were single and without kids I'd pick general surgery, but I don't know if my family could handle it.

Surgery Procedure Log

Endoscopy
7-23-13

Exploratory laparotomy
7-23-13 batteries
7-25-13 free air
8-1-13 - laparoscopic turned open due to tear in stomach; band eroded through stomach wall
8-3-13 - laparoscopic turned open adhesionectomy for SBO: open once small bowel tumor found

Inguinal Hernia Repair
7-23-13 lap bilaterally TEP
7-29-13
8-2-13
8-5-13
8-8-13
8-16-13 lap TEP

PortaCath Placement
7-23-13
8-2-13

Hemorrhoid resection
7-23-13
8-6-13

Trauma wound cleanse
7-24-13

Umbellical Hernia Repair
7-25-13
8-2-13
8-5-13
8-16-13

Laparoscopic Cholecystectomy
7-25-13 x2 one with cholangiogram
7-27 -13 x2 one converted to open
8-6-13 x2
8-5-13 x2
8-8-13

Abscess Incision and Drainage
7-25-13
2x 8-2-13
8-3-13
8-5-13
2x 8-6-13
8-8-13


Skin Removal with wide margins and sinus tract debridement
7-25-13
8-1-13 Forearm excision

Colostomy Reversal
7-26-13

Laparoscopic Apendectomy
7-26-13 x2

Central Line Placement
7-26-13
7-27-13
8-3-13
8-10-13

Chest Tube Placement
7-27-13

Below the Knee Amputation
7-29-13
8-15-13

Colostomy Placement
7-30-13

Right Hemicolon Resection
7-30-13

Hiatal Hernia Repair
7-30-13

Incision and Drainage of Pilonidal Cyst
8-1-13

Ventral Hernia Repair
8-2-13 Laparoscopic converted to open
7-30-13
8-14-13

Back Lipoma Removal
8-2-13
8-6-13

Sunday, August 11, 2013

Seizures

"Hey, how's the patient in 212?"

"Be careful in there. Last night she was pretty agitated and had a headache and seizure that lasted a few seconds, so we gave her some Ativan. She wanted to go outside and smoke yesterday so we told her she could sign the against medical advice (AMA) papers after she finished her current round of IV antibiotics. When we left the room she unscrewed the drip line and spilled them all on the floor. Then some of her friends came last night and when the left she was much more sedated. We think they brought her some drugs."

"Sounds like she'll want to get out of here as soon as she can."

-

"Good morning. How are you doing?"

"Well, as I was just telling the nurse, this morning was the first time in three days that the dressing on my wound has been changed."

"I just checked your record and your nurse said that she changed it last night at seven and I was here yesterday morning when it was changed."

"Well, maybe I was asleep when it was changed."

"Did you take anything for your seizures before you came here. Who is your doctor?"

"I don't have a doctor. And I only get my headaches when I spend about three days in bed."

"How often do you spend three days in bed?"

"Few times a year. Can you come back later? You have two heads."

"I think I'm going to decrease your dose of pain medications since your wound looks so good and I think we'll let you go home tomorrow morning."

Prescription Paper

"I've got good news. Your abscess is getting better and your wound is healing. We're going to let you go home today."

"But where you cut me is still open."

"Your wound is going to close a little bit more each day. We'll give you a prescription for some antibiotics that work against the bacteria that was growing in there."

"So I go home with a big hole in my body that still leaks pus?"

"We've done what we can do for you here and you can finish healing at home."

"Can you give me some of that gauze that you have been changing the bandage with?"

"We don't have any we can send with you, but I can write down what kind we use and you can pick some up at any pharmacy."

"But I'm on the indigent plan, so can I get some for free?"

"And I'll write it down on prescription paper so the pharmacist will know what kind to sell you."

"Okay, thanks."