by Atul Kumar
“Pre-rounds,” as they are called is the time when we individually see our patients before “work rounds” when we go over the plan with the senior resident, finally ending in “formal rounds” when we present each patient to the chief resident. During “work rounds” we gather all the patient charts and place them in a rolling cart so they are ready and available when we round with the chief. During formal rounds all the notes are finalized and orders for the day are written by whomever is not presenting that particular patient, typically the med student or other intern.
As work rounds started, the morning went from bad to worse. I was reprimanded for not seeing the two patients who had been getting CT scans. Apparently I should have gone down to the CT scanner to examine them there. I was dismissed to do exactly that. Of course, by the time I returned, chief rounds had already started and nobody dared interrupt Blake to introduce me.
At the end of rounds the group immediately disbanded and I was left alone not knowing what to do. I thought better of asking a nurse for help given my earlier experience. Instead I just followed the signs towards the OR located in the basement.
I took the “restricted” stairs figuring I was qualified to take them based on the fact my badge unlocked the doors and no alarm sounded. Opening the basement door immersed me into a world of constant activity. It was like entering a beehive, only everyone was wearing scrubs.
I brilliantly spun slowly around in a circle taking everything in when I bumped into an EKG technician and almost knocked over her machine. Instead of being yelled at, she was sympathetic to my plight, “Let me guess, first day?”
“What gave it away?”
“Locker rooms are down that way, you can get some scrubs and change in there. Come back out and head in the opposite direction through the double doors and that’ll take you to the ORs. Good luck. I’m Amy; I’ll probably be seeing you around.”
She was gone before I could thank her. Guess the ORs were a no-nonsense kind of environment.
Being a med student meant that I had no locker or any other place to put my bag or clothes. Thus, I had to dump them in the corner of the locker room and hope nobody stole anything.
By the time I found my way to the pre-operative area, our first patient had already been transported to the OR. So much for a pre-op examination and introduction.
I weaved in and out of scrubbed worker bees, all wearing masks and hats once I entered the OR clean area. After circling three times I finally found OR 18. The rooms are conveniently not numbered consecutively; instead even numbers are in one corridor and odd numbers in another.
As I entered, the door slammed into the anesthesiologist’s cart, immediately garnering everybody’s attention. I identified Dr. Lanky speaking to another scrub-clad individual whom I presumed was Dr. Robor; they were both going over some sort of MRI scan. Lanky shook his head at me; Robor didn’t make any sign of acknowledgement.
The room was quite expansive with numerous bright lights. In the center was a patient hooked up to several monitors and IVs. There was an anesthesiologist and a nurse preparing him for the surgery; another nurse was helping a scrub technician set up the equipment for the surgery and the two surgeons were discussing the case. Pretty impressive. Including myself there were seven individuals besides the patient present for this surgery.
Lanky came up to me, “Ra, you really need to work on your punctuality. Did you get to review Dr. West’s case in pre-op?”
“No, I barely got changed in time.”
“Don’t let that happen again. The patient is Dr. Peter West; he’s a recently retired urologist who was diagnosed with pancreatic cancer. This surgery is the only chance at survival he’s got.
“What size glove are you?”
I shrugged. “Medium?”
“Fuck man, don’t you know your glove size? You look like a 7.5, I’ll have the nurse pull that for you. Do you at least know how to scrub?”
“Yes,” I lied. Sure I’d heard of scrubbing, the procedure of washing your arms from fingertip to elbow before donning a sterile gown and gloves at the beginning of surgery. I also read that it was complete nonsense; in other countries they just washed their hands and had the same rates of infection we did in the US, except here we spent a full five minutes scrubbing our skin with caustic disinfectants before every single case. But I thought better than to notify Dr. Lanky of this tidbit of information.
“There might still be hope for you. Go ahead and scrub, just don’t use the middle sink, that’s Robor’s. I’ll meet you back in here in a few minutes. Don’t contaminate anything; everything that’s blue is sterile.”
I immediately headed out to scrub. After I took two steps I was stopped. “Hey, where do you think you’re going?”
I turned, “Uh, to scrub.”
“Other door over there; be sure you take a piss too. This case’ll be at least 6 hours.” At least the scrub tech didn’t seem like he had a vendetta against me.
I managed to scrub and gown up without complication.
Once the case started, Robor stood to the patient’s right and Lanky to the left. Behind Robor was the scrub tech, and I took up position behind Lanky.
This sucked; I was the shortest of the group, so even on my tip toes I could not see over Lanky’s shoulder. This was how I spent the first two hours of the case, staring at Lanky’s shoulder while they operated. Occasionally I’d get to see a piece of gauze doused with blood.
When a relief nurse came in to give one of the nurses a break, she noticed my precarious position and offered me a stool upon which to stand.
Amazing! My view changed dramatically. I was now looking inside Peter’s abdomen. It was filleted wide open and I could identify the stomach, liver, both large and small intestines, and a sponge-like gray-green structure—the pancreas! They were just completing the Kocher maneuver. I was so enthralled I didn’t even realize I was leaning on top of Lanky until he jabbed me in the stomach.
“Ra, hold this.” Lanky handed me a metal retractor with which to hold the abdominal wall out of the way. My new mission in life was now to make sure the tissue I was retracting did not get in the center of the surgical field.
I must have done well because after 45 minutes of retracting I was handed a second metal retractor. This is how I spent the next two hours of the case, retracting tissues. My fingers, arms, shoulders, and back ached from the constant tension I was applying to hold back the tissues. But at least I was making a difference; I was helping to operate!
The enthusiasm of retracting is short lived, wearing off in about 15 minutes, after which the job became so boring that I started to doze off while standing on my feet.
My bladder also conveniently decided to remind me that it needed emptying. I soon realized this surgery stuff was for the birds. Who in hell, actually, who outside of hell, wants to spend hours upon hours in a cold OR standing on their feet elbow deep in blood and guts with no bathroom breaks, just to do another case after the first, day in and day out?
I kept trying to convince myself that even though my role was minimal, the muscle cramps were worth it; at least I was an active member in Peter’s surgery. I wasn’t.
A new nurse came in the room and announced, “Dr. Robor, the new auto-retractors are here.”
“Great,” the man actually spoke, “let’s break them open.”
As soon as he was handed the ‘auto-retractor’ I was relieved of my duties. Said device replaced what I’d been doing for the past three hours … talk about low man on the totem pole.
Worse still, Lanky took my step stool for himself, so I again got to stare at his shoulder.
Eventually the case ended, 6 hours 30 minutes after it started. The jargon used during the procedure was so intense I didn’t even know if the case was a success or failure.
Robor immediately left the room and one of the interns entered to help close up the main incision. Once again I was left with a view of a shoulder, only this time the intern’s because Lanky planted himself where Robor was stan
ding previously.
After what seemed like an eternity, all the drapes and other sterile dressings were removed and Peter West was taken to the PACU to recover before being transferred to his hospital room.
My feet ached, my muscles hurt, and my bladder had grown to the size of a basketball; standing in an area of two square feet for over six straight hours in dress shoes is not the best use of my tuition money, at least in my opinion. On the bright side, I could use the bathroom now.
“Ra, go with Dr. Parker here to make sure the next patient is ready. I want to start the case within ten minutes so we can get out of here by 8 p.m. and do evening rounds.”
This was not shaping up to be a good day.
I managed to see the next patient and micturate. And that’s all I got to do before the second case started.
The second case was just like the first, only worse. Dr. Parker was in the room as well, so I got to stand behind him the whole six hours. And he was standing behind Lanky, where I stood for the previous case. I didn’t even get to retract. The only ‘operating’ I did was to hand a couple bloody wads of gauze to the scrub tech for disposal.
The first couple hours were OK; I could at least hear them teaching Parker something here and there, so I learned a bit. By hour three, I was bored out of my mind. The teaching had stopped, and my view of Parker’s back from about four inches away hadn’t changed. Not to mention the room was only heated to 60°F and the mask was difficult to breathe through. Thus, I was shivering as well as hungry for oxygen.
At hour five somebody spoke to me, but it was only to tell me to step back because I was in the way.
The case ended at hour six and Robor left the room. I sighed in relief; I could finally see the abdomen. I even got to hoping that maybe I could throw a stitch or staple. That thought was short-lived.
“Ra, I’ll close up here with Dr. Parker. Why don’t you get the next patient prepped so we can start right away.” Except it wasn’t a question.
The third case was fortunately much shorter, just a splenectomy for the treatment of autoimmune hemolytic anemia—wasn’t sure what that was, but it sure sounded bad.
The only benefit during this last case was that when extreme boredom settled in during hour two, the case ended. Thank goodness.
It was 10:00 p.m. My first day of surgery was half over, and all I had done the past 15 hours was stand stationary for three major operations, fill out paperwork, and urinate once.
Again, as they started to close, I was dismissed to go check up on the previous two patients before evening rounds. The only good news was that the other patients I saw this morning were no longer my responsibility. From now on, I was only responsible for patients whom I scrubbed in on during surgery.
By the time I’d located the rooms of the two Whipple patients from earlier in the day; my pager went off with a terse message: RM 643, STAT.
I took off running and bumped into Parker in the stairwell, me descending and him climbing. I guess he got the same page and had to leave the OR. “Move it man, we need to put in a chest tube.” He seemed excited about the possibility of a procedure.
We arrived and there was chaos abounding. I don’t know how, but Lanky was already here. I could have sworn it’d only been ten minutes since I left the OR. He was prepping to place a chest tube in an elderly female who appeared cyanotic and looked two solid decades older than her stated age of 68 years.
“Ah, the team arrives. Dr. Parker, come on over here.” Lanky whispered to him, “Have you ever done one of these before?” Parker shook his head, negative. Lanky spoke even softer, “Well, you’re up, gotta learn somehow.” He proceeded to hand Parker the equipment.
As they prepped the patient for a chest tube on her right side, I grabbed her chart and began to read up on our patient.
Jane Dover was a 68-year-old female who was admitted yesterday for shortness of breath and found to have several lung lesions on her CT scan. They likely represented multiple foci of cancer given her greater than 40 year history of tobacco use and recent unexplained weight loss.
She was placed on supplemental oxygen overnight with the plan of obtaining a PET scan in the morning to continue the work up of her suspected cancer.
Twenty minutes ago she reported pain on her right side and shortness of breath that was worsening despite oxygen. A STAT chest X-ray revealed a right sided hemothorax, which was not present earlier that day and would certainly account for her symptoms. The most likely cause was that one of the cancer nodules had eroded into a blood vessel which had then bled, causing the lung to collapse.
The loss of her right lung was something she would not likely survive unless a chest tube was immediately placed to evacuate the blood and allow her lung to re-expand.
I recalled reading that placing a chest tube could be a very satisfying procedure, as patients experienced relief almost instantly, not to mention that it was a life saving procedure if it went well. But in a heavy smoker it could be quite tricky due to a very small and fragile lung, making tube placement critical and often times difficult.
Instead of holding Parker’s hand and guiding him through the process, Lanky was just talking as Parker did the procedure by himself. I listened in; nobody else in the room seemed to be paying much attention to the procedure. The nurses were all helping hold Jane in position and administering medications or monitoring vital signs.
“Good, that incision size is perfect. Now expand it with the hemostats, excellent.” Parker seemed to be confident in his ability, though I noticed that his hands were shaking. Likely due to either to nerves or adrenaline, I wasn’t sure, but I’d be shitting my pants if I was doing my first chest tube without prior notice.
Lanky handed him a rubber tube clamped within the teeth of a large pair of hemostats. “Here’s the chest tube, I want you to slide it in just above the rib like we talked about and then advance it forward and slightly downward; we should see blood come out almost instantly.” Parker did as he was told and almost instantly dark blood began to flow out.
“Good work. Now go just a little further, good. Keep going. Yeah, just like that … a little bit more, you just have to be careful not to … FUCK!!”
Suddenly the right side of her chest deflated and the bleeding turned from a dark burgundy to a bright red.
Lanky literally shoved Parker aside shouting, “Occlusive dressing STAT. Get an OR NOW! We gotta open her up and get this fixed. Call Dr. Blake and have him meet us there.”
The three nurses in the room dropped what they were doing and immediately began to wheel the bed towards the trauma elevators. Within 20 seconds the room was barren except for me and Parker. The others were well on their way to the OR.
I looked to Parker; he didn’t seem that worried. He took off his gloves and was the first to speak. “Guess we should finish up rounds.”
Maybe it was just me, but I felt that a modicum of emotion was in order. I know I’m not a doctor yet, but even I knew something really bad just happened. From what I could tell, the right side of her chest suddenly decompressed, meaning that the blood had to have gone somewhere. It clearly didn’t come out of the tube, which meant it likely went into the abdominal cavity. The only way that could have happened was if the diaphragm got punctured during the procedure. The bright red blood that suddenly appeared was probably secondary to a laceration of the liver because the tube was advanced too far and too aggressively.
Translation: serious complication.
I wanted to ask him about this, but Parker was already out the door headed up to the seventh floor.
“Uhh, shouldn’t we go to the OR?”
“No, Drs. Cooper and Blake will take care of it. Our job is to manage the patients on the floor.” He clearly didn’t want to talk any further about what happened.
I wanted to ask how he managed to rip through the diaphragm and tear into the liver, but I figured it was best to keep my mouth shut if I wanted to pass this rotation. After all, it was July, the absolute worst time to
be a patient at any university hospital; that’s when all the new interns start. Many studies have shown that the rates of death and number of complications that occur in July and August are significantly higher than other months, likely due to episodes as I just witnessed.
What really irked me was that Parker had no remorse about his actions; in fact, he seemed unfazed by the experience. If I’d done something to cause someone a potentially life threatening complication requiring high risk emergency surgery I think I’d be quite shaken up and seriously re-evaluating my life, and probably even considering another career path.
The lack of empathy pissed me off, coupled with the fact I had to refer to interns as “Dr.” I decided surgery sucked. Surgeons live in their own little egotistical world—a world which has some of the highest rates of divorce, adultery, alcoholism, and other unsavory statistics. Surgeons also log in some of the longest hours of any occupation on the planet and take home paychecks with lots of zeros … somebody’s gotta pay the alimony and child support.
Though I didn’t know it at the time, I’d learned an important rule: in medical training, a lot of what you learn is what not to do and how not to act by watching others.
I tried to get a bite to eat, but the cafeteria was closed. The surgeon’s lounge had already been raided and all that remained were some half eaten cookies and soda. Bon appétit … at least they were calories that’d keep my blood sugar up throughout the night.
Eventually I made it to Dr. Peter West’s room, our first Whipple patient from the day, and knocked on his door. The lack of response clearly meant I should enter; hospitals have no sense of privacy. I was quickly greeted by a well dressed woman who looked to be about 50—either he robbed the cradle or she aged extremely well. Dr. West was sleeping and appeared quite sedated from his anesthesia.
“The good doctor’s wife, I presume?”
“Yes, pleasure to meet you,” she shook my hand, “Doctor?”
“No, name’s Raj, I’m the medical student. I was observing your husband’s case earlier today.”
“Oh, nice of you to swing by. Bert stopped by earlier and told me the case went extremely well and we should know in a couple days if it was curative or not. Unfortunately, I’ve read all about pancreatic cancer and that poor Peter’s chances are only 10% for a cure and living to see this month next year, given the size of his mass.”