Blood, Guts, and Feces

Ok, ok, I know it's a gross title, but some of the surgeries I have participated in are.....well, with no intent to disrespect the patient, gross. I have had the pleasure of working with a colorectal surgeon in the past week. We have repaired anal fistulas, removed polyps in the rectum, and last night, attempted to remove a large cancerous tumor of the colon that was stuck to the bladder.

What's a fistula you may be wondering? That's a hollow tube or tract that develops between two spaces (IE, between two hollow organs, or between a hollow organ and the outside world - the biggest empty space of all). These fistulas stay open and are unable to close due to several different mechanisms, so handily memorized by the oxymoronic mnemonic FRIEND - foreign body, radiation, infection or inflammation (like Crohn's disease), epithelialization (that's the process of skin or epithelial cells laying down a tract where they shouldn't be), neoplasms (cancer), and distal obstruction. Fistulas can develop between the large bowel and the bladder or vagina, or between the large bowel and the skin. (see photo above)

That's what happened to one unfortunate fellow whom we operated on - he had developed not just one, but two fistulas from his rectum to the skin outside his anus. This meant that fecal matter was coming out not just his anus as expected, but also out of the two fistulas near by. This patient developed these fistulas after some rectal abscess or infections that pushed their way out toward the surface of his skin, and then became epithelialized. Our job as surgeons were to go in and get rid of these fistulas so that the patient could resume normal bowel habits. This was much easier said than done.

The colorectal surgeon I worked with on this case, and several other cases involving the rectum (how does someone voluntarily choose this speciality????), had no inhibition about working in this area of the body. Shortly after gowning and gloving up he dove right into the case, all excited to show me, (literally by grabbing my gloved hand and pushing a finger into this patient's anus) the difference between the internal and external anal spinchters. These are probably two of the most important muscles in our body, allowing us to operate normally in the world, without poo falling out on it's own accord (medically referred to as fecal incontinence, not something you ever want to happen to you).

The nurses referred to this surgeon as a mad scientist, and they were right. He dove into this guy's rectum with such vigor, (no need to worry the patient is blissfully sleeping with the anesthetic drugs), it's like he's forgotten that the blood and stool on his fingers and instruments are in fact, blood and stool. Nothing seems to phase him. Not even the profoundly strong smell of feces, accentuated from time to time with loud farts, which myself, the nurses, and the anesthesiologist warded off with peppermint oil dabbed on our face masks just under the nose. Either he no longer has a sense of smell, or is so desensitized to the smells that it's become a normal part of this daily life.

After we identified both of the fistulas with our instruments as well as with blue ink that stained the tract from the skin to the rectum, the surgeons job was to then gently find a plane of dissection between the inner and outer spinchters I previously mentioned. This is such a crucial part of this surgery, because to cut something inappropriate, like a nerve or the spinchters themselves, could very well leave the guy with needing Depends diapers for the rest of his life. While moving into the tissue we did come across something unexpected, a spurting blood vessel - an artery. One clear way to determine in surgery whether or not you have cut a vein (which carries unoxygenated blood back to your heart) versus an artery (carried oxygenated blood to all of your body's tissues) is the force and pattern of bleeding. If it pulses and spurts, it's an artery, and that's what he accidentally cut. Still, the surgeon was not phased as blood shot out from this patient's anal area and covered the front of his body, gown, mouth mask, and eyeglasses, not to mention the spatters on his exposed neck and forehead, to which the nurses immediately got all agitated about.

One of the jobs of the nurses is to keep both the patient and the doctors safe, by making sure that the doctors are completely sterile at all times (many times I saw the scrub nurse force a surgeon to change his gloves if she thought his hand or arm went out of the sterile field), and in this case, all the nurses wanted to do was to wipe off the blood from this surgeon's forehead and neck. But he would have none of that; there were more important things to do - like stopping this artery from spilling too much blood, and returning to the task at hand, finding and obliterating these fistulas. He seemed to have no worries at all about whether or not the patient was positive for Hep B or C, or HIV.

And so we continued on, stopped the bleeding, and backed out of the plane of tissue we were in, since usually, according to the surgeon, the place he was looking for did not usually have blood vessels. Two hours later we finally finished the case, woke up the patient, and moved on to the next operation. It was so bizarre to look this patient in the face when he woke up, after having spent four hours looking at his anus with his legs up in stirrups. Such is the privilege we have in taking care of patients. We see and do things that seem so unnatural, and yet are so necessary for people to get healthy and restore dignity to their lives.

Unfortunately for the patient we just operated on, he returned to the ER one day after his discharge with severe bleeding from his rectum, and the nurses called us in panic, sure that he was "bleeding out" or in medical terms, exsanguinating. Luckily for him we took him back into surgery to stop the bleeding, he was transfused (given extra blood due to his loss), and eventually sent home. I wonder if the surgeon had any remorse or felt any guilt for the artery that was accidentally cut. One things for sure, there is no way on earth I would ever be comfortable operating on patients' rectums. No, that's a part of the human body, along with the rest of the internal organs, that I am just as happy to look at from pictures in a book. The real thing is much too slippery, bloody, and smelly for me. The image of this surgery will stick in my mind forever, and I'm afraid of what will happen the next time I smell peppermint oil.

Vascular Surgery

I have found it to be true what all the previous students have warned us about the clinical years of med school - it's all team dependent. It's not such a novel concept actually, and can be applied to all areas of life - what you experience is directly dependent on who you work with. I am happy to say that the previous 75 hour work week was much better the the first one, but still not enough to make me jump out of bed with joy when my alarm goes off at 4:30 am, or enough to keep me awake past 10 pm studying for the next day. I got to work with a new "team" of residents and attendings (the "bosses") during this past week, and it was an improvement over the first week, if only because I finally got to actually do something during surgery. Oh sure, there was the usual "pimping" or endless stream of questions about the anatomy of the blood vessels, or the pathophysiology of blood vessel disease, or the indications for surgery for aneurysms, but at least I was able to both cut the skin, and suture up wounds. I was painfully clumsy as indicated by the deep sighs by the attending trying to show me how to tie knots with shaking hands and bloody gloves. Why can't they remember what it was like when they didn't have the stellar dexterity of single hand knot tying?

Yes surgeons don't win the prize for the most amount of patience, or the most compassionate way to tell a patient they are going to have to cut off a leg the next day due to the peripheral vascular disease causing necrotic dead tissue in the toes and foot. They do however, take the cake for their skill with the knife, with controlling bleeding, and with making life and death decisions while under extreme pressure. I am sure that I could learn how to tie knots faster (and was sent home to practice knot tying with some supplies), and I could relearn the anatomy of the human body in such detail that the names of the branches of the external carotid artery would roll off my tongue as fast as the names of my siblings. I believe however that in the process of learning these skills I would leave behind something much more important to me - the life and experiences of the patient. In just two short weeks of surgery I have already learned to minimize the patient to the exposed limb under the sterile drapes. In fact, there were times when I was a bit startled with the rise and fall of the lungs due to ventilation assissted breathing, or the jerk of a limb as the patient started waking up from the anesthesia.

Yes there is a body underneath all those layers of sterile blue drapes, a body with a mind and heart that is sad or angry or pissed off at having to go under the knife. I won't deny that I did enjoy the surgical part of the previous week. In addition to finally getting to practice my suturing, and electrocautery (that's using a small electric device to burn small blood vessels and stop them from bleeding - bigger vessels need to be tied off - something the more proficient vascular surgeons took care of while I suctioned up all the blood pooling under the exposed limb). By the end of the week I was capable enough to actually amputate a gangrenous (dead) finger, with the verbal guidance of the attending close by. I actually felt guilty cutting off this guy's finger, not because it wasn't necessary, but because while meeting him in the preop area to consent him prior to surgery he asked in a worried voice whether the "student doctor" (that's me) would be cutting anything. I reassured him that the real doctor's would be the ones. and that I would be merely watching and learning. Of course at the time we spoke I had no idea that I would be allowed into that hallowed space of actually participating in the surgery, but I felt guilty none the less, as if I had broken a promise. Another reason I wouldn't be a good or effective surgeon - too much feeling, and not enough.........hmmmmmm........

I'm not really sure what I don't have enough of to be a surgeon. Of course I have forgotten most of what I have learned in the past two years, maybe because I didn't really store it into long term memory, but merely memorized the information for the next test. I was always a good test taker, but the long term memory I believe won't come for me until I have context, or a foundation upon which to hang the newly learned information. You can be sure that I will never ever forget the arteries and nerves and muscles of the lower leg, as I helped to cut through the skin, fascia, muscle, artery, vein, nerve and even the bones, of a poor man who had to go home for a few days in order to prepare himself mentally to lose his leg. And you see, it's that part of the patient that interests me more - the discussion about losing his leg, the discussion and plan for post surgery recovery, and the plan for rehabilitation that has led me down this path of medical school. No the cutting is not really my thing, although I will continue to do my "duty" in the next three weeks, of workings 13 hour days, a 30 hour shift once per week, and withstanding the relentless pimping by capable surgeons. I can only hope that I will not have to go under the knife in my day, now knowing what goes on once the patient falls asleep. Cheers!

Why I Don't Want to Be a Surgeon

I'm sitting in a tiny room stuffed tight with a bunk bed, table, chair, computer, and phone (think college dorm room, but 10 times smaller), somewhere in the bowels of the hospital. I'm on call. I can't even remember if I have written something about call nights yet, that's how my brain is these days, worn out, and incapable of remembering things I definitely should know. I'm waiting for the trauma pager to go off, at which point I will rush down to the ER, meet the resident who's also on call that night, and determine whether a trauma patient is going to need surgery or not. This is my first night on call in the surgical rotation, although I'm not a complete virgin, since I did 4 call nights while rotating through Pediatrics. Not sure if I will get sleep or not, and the truth is, I'd rather be awaken by the pager then sleep all night. I learned more on the call nights I did in Pediatrics then I ever did during the day shifts. It's probably because when on call there are fewer residents and students around, so that you actually get to do, and therefore learn, much much more.

By I digress away from what the first four days of my surgical rotation have been like. 4 days down, 31 to go. Does that give you any clues? My first day was spent all day in lecture, learning about suturing, trauma, anesthesia, and other tidbits that we need to learn, not only to take care of patients, but to pass the surgical exam which happens on the last day of the rotation. The second day was surgical clinic, which began with a five minute instruction on how to use the VA medical records system, including how to do a chart note, put in the doctor's orders, and set up the encounter for billing purposes. Then a nurse comes up to me, hands me a chart with a four page questionnaire, and says please have Mr. So and So fill this out, he's in room B9. Off I go to do my job, and meet a very sweet retired vet (my rotation is at the Veteran's Hospital), who answers all my questions. I was told by the nurse to then go present the patient to one of the attendings. So off I go to find the attending doctor, and I begin to let him know all the things I had written on the questionnaire. Very soon into passing off the information, the doctor starts asking me questions that I did not have the answers to, including the fact that I had no idea what medications the gentleman was on, and even worse, I didn't even do a physical exam! I rapidly realized that what I was supposed to do was a complete history and physical exam on the patients, and then present my assessment and plan to the doctor. All I had done was ask him the questions on the sheet the nurse handed me, and only later did I learn that the questionnaire was just a way the nurses were gathering data for some study they were doing.

That is just the beginning. After admitting to the doctor that I did not do the physical exam, (and feeling like an idiot), we went and saw the patient. All went well with that patient. Then I went to write my notes, had a terrible time getting into the computer system (remember the 5 minute training....yah, five minutes wasn't enough), all the while the doctor is coming up to me and rapidly asking me to add things to my note, like ordering a EGD, manometry (what the hell are those I'm thinking), and sending my note to so and so, and so and so, so that they can set up these studies, all the while nurses are coming up to me to ask if I'm ready yet to see another patient. By the time I got to see my second patient, I was beginning a stress headache that would be my friend for the whole rest of the day. So I did the history taking and physical exam right on the second patient, and went to find a doctor amidst all the people milling around, to present my patient to (behind the waiting room doors, the clinic is pure mayhem). I find a different doc this time (thank god, cause the first one has definitely decided I am impersonating a third year medical student), and present a great summary of what the patient is here complaining of. Then she asks me what I want to do about his gallstones, which are causing him pain and discomfort, and have been seen on an ultrasound. I struggle in my brain to remember what do we do about gallstones, and I'm wondering if there is some medicine we can give to help them pass? Or maybe we can break them up (wrong stones, I was thinking about kidney stones), and finally just looked at her and admitted "I don't know what to do about gallstones." She looked at me like I had three heads, and calmly replied, "we take out the gallbladder." Wake up Valerie, you are on your surgical rotation....and so the doctors are here in clinic to see if the patients need something cut out!

Oh my god, another doctor who is going to evaluate me on this rotation who I have totally blown it with. I can just imagine her and the other doc talking later. "Hey my student didn't even do a physical exam on her first patient," while the other replies "That doesn't surprise me since she didn't know that we remove the gallbladder for symptomatic gallstones." By this time my headache went up a few more notches, and off I went to do my note in the computer until the nurse forced another patient down my throat. The last patient was easier, a woman with a lump in her breast, in to see if it was going to be biopsied or not. The last doctor I presented to (a different one) thankfully did not ask me any questions that would further destroy my reputation. Only three patients and I was completely exhausted.

The next two days were spent in surgery, where I continued to commit more faux pas. Let's see, I left the room at the end of a surgery before the chief resident did (and got blasted for later); I wore long sleeves into the OR; I didn't finish my note from the morning prior to going to surgery; I wore the wrong color scrubs (dark blue for the VA, light blue for OHSU); and didn't grab the basket of surgical supplies while rounding (seeing) all the surgical patients in the morning. The worse part about making these mistakes is that no one told me, or my fellow students, what they expected of us, and what proper operating room etiquette is, until we screwed up. That is the first of many reasons why I don't want to be a surgeon. When they get to the "top" they forget what it was like to be a student on the first surgical rotation, new to the operating room and all the unspoken rules. Not every surgeon is arrogant, and mean, and difficult to work with, but the few that are spoil the whole rest of the bunch.

More to come as I finish the next 5 weeks, but for now, I should get an hour or two of sleep before a trauma rolls in. Cheers!

Golden Weekend

I have a blessed two days off after just finishing my pediatric rotation yesterday, and just before starting surgery Monday; hence the well known term in Medical lingo - a "Golden Weekend". So what am I doing in these two wonderful patient free study free days? First of all, sleeping. I took a nap yesterday afternoon, after finishing the pediatric shelf exam. Even though the next two years have us students working in the hospital, we still have to study on our own time to pass an exam at the end of each rotation. The extra studying is necessary because in 5 short weeks there is no way that we will see patients with every possible disease or condition that we are expected to know about. Anyhow, the pediatric exam yesterday was hard to finish in the allotted time, but the topics were all things I had studied for....doesn't mean I didn't guess a lot, or that I didn't get some wrong, but I feel confident that I passed.

Which brings me to a side note before I discuss the rest of my plans for the weekend. During this rotation all of us got back our board scores. I felt very confident that I did well on the board exam - based on my average from the first two years of medical school, from the two practice tests I took in the weeks prior to the test, and from how I felt after leaving the exam. While I did pass the exam, my score was way below what I expected, and way below average for all students that take the exam, and below average for the speciality that I want to go into. Boy were my spirits crushed the day I checked my score. I didn't have too much time to dwell on the test result though as I continued to take care of kids in the hospital.

So why the lower than expected score? Either one, I am not as smart as I think. Two, the test was a lot harder than I thought. Three, there is a conspiracy out there to separate students into bright, very bright, and ridiculously brilliant in order to still have students going into primary care (which has the lowest board scores). At this point it doesn't really matter why, because I cannot change it, and I cannot take it again (you can only retake it if you fail, and this is worse because residencies will see that you failed the first time). How can I balance out this low score? I can take my step two board exam prior to applying to residency (which I will do), and I can rock my third year rotations, busting my ass so that I can get good grades in the clinical years. In my mind I know that it is not the end of my life that my score is less than what I wanted, and that my other skills will balance out this stupid test, but I have to be honest that it hurts. It's like I was not able to achieve something that I really thought was not only possible but inevitable. I knew that I would get into medical school, that I would get into OHSU, that I would do well in the first two years. There has not been many things in my life that I have not achieved once I set my mind to it. So a low board score is humbling, frustrating, and sad. Even though I know that I don't want to be a surgeon, it's sad to me that that door is now definitely closed to me.

But I digress. So despite the board score news, I was able to keep up with the demands of the pediatric rotation, which as compared to other rotations, I've heard through the grapevine, is totally mild. While I love kids, I have to say that it's really sad to see them when they are so so sick. I had a 7 year old patient that I followed for two weeks with Cystic Fibrosis, who almost died of her lung disease in the first few days of her admission, but by the end was singing Michael Jackson "Man in the Mirror" and showing me pictures of her dog that she couldn't wait to go home and see. When I said goodbye to her and her family, I did so knowing that she could be back anytime in the next few months with a flare up and that she wouldn't live to my age.

I took care of kids with osteomyelitis (bone infections,) viral gastroenteritis (severe dehydration due to vomiting and throwing up), failure to thrive (babies who don't gain weight), bacteremia (blood infection), accidental ingestion (of medications, lamp oil, and one girl swallowed a button battery), and the worse of all - Non-accidental trauma (child abuse). The abuse cases were the hardest of course. Our attending doctors told us that during times of stress and economic struggles (recession), the cases of child abuse increase. I saw babies with "shaken baby syndrome" (bleeding in the brain from being shaken so hard that the brain hits the skull and swells), broken bones (ribs are common, as well as chip fractures from where muscles attach to bones - this also occurs with shaken baby syndrome - from a type of whiplash of the arms and legs), bruises, (any bruise of the abdomen, back, or ears are suspect since this is not where kids tend to get bruises from falling), and burns (anything that looks continuous in shape - like a cigarette burn or a curling iron, since true accidental burns tend to have a splash pattern). I got used to seeing policeman and DHS (Department of Health and Human Services) in the hallways, taking pictures of the wounds, and interviewing family members. I saw parents being forced to leave, with anger in their eyes and tears on their faces, while their children were left in care with the State officials.

If that isn't enough to depress you, then the last day of my pediatric rotation will. There was a two year old girl who was just discharged to go home (discharge occurs when all the physicians and specialists involved in the childs care feel the child is medically stable and no longer needs inpatient care), and she was in the shower with her parents, all excited to go home and get back to their regular routine, when disaster hit We were in morning report, which is a 30 minute teaching every morning for the residents and students, where a case is presented, and everyone thinks aloud about how they would take care of the patient in question. During this morning report several pagers go off, which is not unusual when you are hanging out with physicians. Lab results, nurses questions about care, and information about new children being admitted all come over the paging system. But this time after a page, two physicians in the room jumped up and went running out of the room. A code was called. "Code" means that a patient has stopped breathing, or is in severe respiratory distress, or worse, that the heart of the patient has stopped beating. Every day there are several physicians who are on the Code team, meaning that in addition to their regular pager, they also carry a code pager, in order to attend to any pediatric patient that stops breathing.

So the two residents bust out of the room, and we all wonder what is happening as we try to concentrate on the rest of morning report. It is only later that we learn that the two year old girl stopped breathing, and her heart stopped beating, and that the team of physicians tried to get her heart started again for over an hour. My classmate was one of the ones who got to do chest compressions (trying to pump the blood in her body to her brain, since the heart isn't doing it any longer), while the surgeons tried to get access to her arteries to hook her up to a machine called ECMO (extra-corporeal membrane oxygenation - essentially a machine that removes her blood, gives it oxygen, and returns it to her body). After a night on the ECMO machine, and evidence that her brain had been without oxygen for too long and had suffered irreparable damage, she was taken off the machine, and died.

Our team was devastated. The resident left the room after telling the family and cried. The attending doctor tried to understand how this could happen. In the kidney doctors' many many years of practice, they had only ever heard of this happening once to a patient in her condition. She had a condition called nephrotic syndrome, which means that her kidneys were loosing protein in her urine, and that she therefore had some problems with maintaining appropriate blood pressure (it was too high). The condition also has the minor side effect of making the blood more sticky - or coagulable in medical terms. And this is how she died - a large sticky clot broke off and clogged a major artery to her heart.

So it was a sad end to a rotation that was filled with joy (when the patients got better and went home), a sense of futility (knowing my Cystic Fibrosis patient would be back, and would die of her lung disease sooner rather than later), frustration (with not understanding sometimes why a child was sick, or with dealing with understandably overbearing parents, or worse, uncaring and even abusive parents), and sadness (sometimes things happen, like death, that we cannot foresee or prevent). Tonight I'm going to a get together with other med students, who were in other rotations this past 5 weeks, where I hope to vent, and get support for all that I have seen and experienced so far. One thing that will be golden for sure, is the nice cold beer that I wash down some tasty ribs with. Cheers.