Gyn Onc

The other half of my OBGYN rotation was what’s known in shorthand, Gyn Onc, which stands for gynecological oncology – cancer of the female reproductive organs. So for two weeks I saw patients who either already had been diagnosed with cervical, ovarian, uterine (endometrial), vaginal, or vulvar cancer, or who had a tumor of unknown malignancy and we had to operate in order to get more tissue for diagnosis. That meant, unfortunately for me, two more weeks working in the OR, which is by far my least favorite place to be in the whole hospital. That’s how you know that you aren’t meant to be a surgeon – if the thought of scrubbing in leaves with a feeling of dread, than you’d better pick a specialty that never steps foot in the OR.

It’s not that the surgeries themselves aren’t incredibly fascinating, or that I don’t feel a rush of power when watching scalpels cut through skin, and I certainly don’t get light headed or feel like I might pass out at the sight of blood. No, it’s just that I always feel like I have to be ready for combat when going into the OR, in part because it’s such a foreign environment, and also because as a medical student, you always are doing something wrong. And by being the very bottom of the hierarchical chain in the OR, well below the scrub nurse (the nurse who’s in charge of making sure the environment is always sterile, and who hands the instruments to the surgeon), means that you are left to the whims and attitudes of those above you.

Of course I made mistakes. I didn’t dry my hands correctly with the towel the scrub nurse handed me; I wasn’t supposed to sit down during an 8 hour surgery, because then I’m no longer sterile (even though the back of you is not considered sterile); I messed up staying sterile while trying to put in a catheter not once, or twice, but THREE times, as I had only been trained prior on a plastic replica of a female’s vagina and urethra; I didn’t suck blood away quickly enough, or I used the suction at the wrong time; I didn’t cut the sutures short or long enough; I didn’t put the staples in the skin straight enough. It’s not that I am above learning from mistakes, it’s just that it is so mentally exhausting to be reprimanded continually, while never ever ever getting any positive feedback. I did work with one surgeon during those two weeks who said please and thank you, and said “good job”, giving encouragement to myself and the resident, and I remember thinking, she can’t really be a surgeon, she’s just too damn nice.

The surgeries themselves were also at times quite long and depressing. While we all would hope that the tumor we removed was benign, most of the time the pathologist would call up to the OR with the results of the tissue sample we just sent them being positive for malignancy. Which usually meant that we had to open up their abdomens a bit further, so that we could take out the uterus, fallopian tubes, and ovaries, as well as getting local lymph nodes to determine how far the cancer had spread. This was the trickies part of the operation, as the lymph nodes are very close to major blood vessels, including the abdominal aorta (the vessel that comes right from the heart, and delivers blood to the lower body), as well as the IVC – inferior vena cava, the main vain that drains blood from the lower body, returning ti to the heart.

One case we had was one of those that we crossed our fingers in hope while waiting for the pathology report, but in fact came back as cancer. As the surgeon was carefully removing lymph nodes from the patient’s aorta, the IVC started bleeding, as there was a little tear. The surgeon quickly asked the scrub nurse for a clamp, which was quickly put on the hole. We thought we had taken care of the problem, when we noticed the patient’s abdomen was filling up quickly with dark venous blood (blood from arteries looks quite different, as it has more oxygen yet to be delivered to the tissues, it is bright red blood, while the venous blood, depleted of oxygen after delivery to the tissues, is a darker red blood). The surgeon asked for another clamp, but we couldn’t find the hole as the IVC had turned underneath the aorta right where the tear was developing. The anesthesiologist looked over the sterile blue sheet asking if everything was OK as the patients pressure had just dropped a lot, and her heart rate shot up as her heart attempted to maintain cardiac output. He had a look of condemnation in his eyes when the surgeon relied, we have a tear in the IVC. The surgeon asked for the circulation nurse (that’s the one that’s not scrubbed in or sterile, so he or she can go get more instruments, answer the phone, or do any anything else that’s needed), to page the vascular surgeons. About 10 tense minutes later two more surgeons rushed in, asked the nurses to open up the vascular operating kit of instruments, and we stepped aside so they could do their magic by so delicately sewing up the 3 cm tear in the IVC. The patient did OK, lost only about 1500 ml of blood, but did require 3 units of transfused blood during this whole process. What started out as a 2-3 hour surgery turned into an eight hour one, and thankfully the adrenaline was able to keep me standing upright for that many hours, without any food, water, or bathroom break.

Upon returning to work the next day, after I dropped into bed exhausted, I found out the distressing news that a surgical sponge was left inside the patient’s abdomen and she had to be taken back to the OR after I left to find it. You hear stories about things like this happening, and usually there are very strict protocols that keep this from occurring: all the sponges are counted in the beginning, and in the end before sewing up the patient. The same goes for the instruments, they are counted before and prior to closing, just in case something was left behind. In this patient’s case, we did an x-ray at the end of the case, while the patient is still on the table under anesthesia, as the nurses “lost count” of the instruments. The said it was because they had 3 sets of instruments opened, and they got confused. The first set was the laparoscopic set we used to just get out the small tumor (laproscopic is less invasive, uses just small incisions, with a camera and long tolls that go into the abdomen, and is a much faster recovery for the patient). The second set of instruments was for the opening of the abdomen, which we had to do when the pathology came back positive for cancer. The third set was for the vascular surgeons, when they came in to rescue us from the IVC tear. So to be safe, we x-rayed the patient, and did not see any metal instruments. Later when a more experienced radiologist read the x-ray he could see the small faint line of metal in the surgical sponge that was mistakenly left behind. The makers of the sponges purposeful put a line of metal in the fabric for this very reason.

To make matters worse, the following day the patient developed shortness of breath and difficulty breathing, due to pulmonary embolism in her lungs. That’s when small blood clots, usually from the veins in the legs, break off, travel up the IVC, into the heart, and then over to the lungs, to get wedged into small capillaries. I’m sure this occurred since we were mucking around with her IVC for so long, although it’s also possible it just came from the veins in her legs, even though every surgical patient is given compression devices for their calves and medication to stop blood clot production. I imagine this patient will probably be suing the hospital for all the complications, but I wonder if it will even matter, since the type of cancer she had was a very aggressive kind, with little chance of survival even with surgery, chemotherapy drugs, or radiation. Makes me wonder if maybe the best thing we could have done for this patient after finding out her pathology, would have been to remove her uterus and tubes, but leave the nodes well alone. It’s a relief for me to know that I won’t have to make these life or death decisions in my speciality, for I think I would have a very hard time sleeping at night.

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