Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Friday, July 20, 2007
"Do you want a foley?" nurses frequently ask before the beginning of abdominal operations -- referring, of course, to the patient. "No," is my invariable reply. "I peed before I got here." "Hah hah." I'm guessing at least a few people wonder: do surgeons ever need to, you know.... The answer is a resounding "occasionally." Many of us, after all, are physical beings.
I've had to take a bathroom break only once or twice in a pretty long career. And it was for the other, er, number. Certain intestinal disorder, don't you know. And yes, it's embarrassing. The leave-taking, the walking past the front desk ("Done already, Dr. Schwab?" "No, uh, taking a little personal time. Be right back. Gotta go..."), the looks on faces at my return. Eyes and foreheads are pretty expressive, above surgical masks. Nurses, being decent human beings, are likely to worry, "Are you OK?" Anesthesia folk, ever witty, can be counted on to say something pithy. Nigel or Lynn, especially. "This should be refreshing. Finally you're less full of it." I can take it.
More common is flagging during an especially long, physically and emotionally taxing case; particularly late in the day, or during or after a long night on call. More than a few times I've asked for a shot of orange juice. It never tastes better, nor has more power of rejuvenation. Some poor nurse has to hie to the fridge in the lounge, scout up a straw (the bendy kind), and wiggle it behind my mask (first making an opening with a finger), while I lean toward her or him to keep from contaminating my gown, and use prehensile lips to try to arrest the tip and insert it into my mouth. Glug, glug. When it's cold, it's sesqui-orgasmic. I've also had candies digitally inserted behind my mask and guided to my lips. I always assumed the nurses didn't find it particularly appealing to do; but I've never been more grateful.
Angels of understanding, there's a couple of nurses -- ones with whom the relationship goes way back -- who've ascended a step-stool and given me a neck rub after I've stopped for the second or third time, leaned back from the table, and stretched. Oh man!! I flap my foot like a belly-scratched dog, and swear devotion till death.
Eschewing cold medicine, I've put a layer of gauze in my mask, under my nose. Drips. And, slightly off topic but nose related, I've gratefully accepted a swipe of benzoin (for its aroma) onto my mask when encountering a particularly putrid pus-pocket, or a well-rotted intestinal infarction. (Actually, I've used it pretty rarely: I've always thought draining pus was among the more noble things a surgeon does: and when it stinks up a room to the point of turning green those who must stay, and driving away those who can find an excuse to exit, there's no need to wonder if you're doing good for the patient. So, in a way, I like it. Dead bowel? Not so much.)
In the operating room, I've been poked, stabbed, cut, and cauterized. My left index finger bears the scar of a scalpeled flap, a centimeter at its base, equally tall: the result of an episode in training that sent me to the ER with a spurting digital artery, and after the sewing-up of which I returned to find my attacker/assistant (it was one of those rush-jobs: as I was ten seconds into opening the belly in the midst of a flood of blood, he reached to pinch off the aorta, banging my elbow...) happily repairing the patient's iliac artery as the attending looked up with amused eyes skrinkling above his mask.
Somewhere along the line, I converted my hepatitis antigens: probably from a needle-stick at San Francisco General Hospital, only a few years before HIV ravaged the place. Digging my way behind the rectum in a deep and narrow male pelvis, I've shaken cramps out of the palm of my hand. The backs of my knees have ached and the fronts wobbled as I leaned for hours into a tough dissection. I started wearing support hose in the OR way before middle age. Stasis dermatitis (mild) made itself known while I was Chief Resident.
If there's a point here, it's this: much as I like to emphasize on this blog that surgery is a thinking person's sport, there are times when it's all about the body.
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Colds are the worst. I've had to jam kleenex up both nostrils to stem the tide of clear snot saturating my mask.
Needle sticks are a constant annoyance in the OR. I get stuck several times a week. My fingers go numb when I try to double glove, so i guess I'll have to deal with it. I remember doing an AV fistula on a dialysis patient when I was a third year resident who had florid AIDS (Cd4 count <20). At the end of the case my attending said something about some other patient on his way out the door and I took my eyes off the field and somehow jabbed my thumb with the suture needle. Nothing more terrifying than seeing the red smear of blood running down the inside of your glove when you're working on an HIV positive patient. I'd just gotten engaged that past week. So then I had to sweat out the next three months while on quadruple anti-retroviral therapy until the final blood tests came back negative. Bad times.
Interestingly, there has never been a case of transmission of HIV from a needle stick in the OR. The highest risk medical personnel are actually phlebotomists and nurses who do a lot of blood draws and IV insertions with the hollow bore needles. Hepatitis is a different matter. I can't imagine there are many liver transplant surgeons who aren't Hep C positive.
I don't know about support hose. There's something a little too Dame Edna about them for me. I wish there was a product that didn't make it sound like I was some sort of weekend cross dresser. Can't we call them "calf toners" or "leg firmers" or something?
I think neurosurgeons doing a difficult, long crani case that might last 12 hrs total perhaps routinely have breaks of one kind or another, they would have to.
I'm 20 years old, and I've been thinking a lot about what I want to do with the rest of my life. I should have started college 2 years ago now, and it really feels like time is running out.
My fiancè who's had a couple.. lets say "extended hospital visits" has got me really thinking, life's a lot shorter than it should be.
I've wanted to be a surgeon for as long as I can remember, and I was trying to convince my self to throw the idea away. Mostly because my fiancè worries it would take too long to become one (and thus take longer to stabilise our futures together).
But a few weeks ago I was looking up fun things like gallstones and I stumbled over your blog.
Maybe you'll think this is strange, but I thought you should know, you've inspired me to push back and become a surgeon. This is too beautiful to miss out on. And if I'm gone before I can make it, no one can say I didn't try or gave up too soon.
Thanks a lot.
I'll be looking for your book I hope you've put it out in Italy... or at least on-line!
-and just so there's some connection to your post, I'd like to add in that I always wondered how surgeons managed during long surgeries!
jeri: what nice words. I'm a little thrilled, and a little worried: if you become a surgeon, I hope you won't curse me some day at three in the morning. As to my book, I have no idea if it's in Italy. It's not readable online, although it can be purchased online, via a couple of links on my blog, or various other booksellers.
Great post. I am impressed by the physical stamina of surgeons. I intended to be a surgeon until I got invited by my mentor to scrub into a Type I Aortic Dissection case as a first-year med student (oh, what glory this accorded me among my peers!). Since I had been a surgical orderly for several years I knew my way around a sterile field and had a decent idea of how to assist, and I managed to acquit myself very well.
But somewhere around Hour 8, I realized that I just did not have the requisite attention span to do this type of thing. I actually caught myself thinking "Fuck it. Let's just close her up and see if she lives." And I knew that surgery was not going to be for me.
Fortunately, then I discovered Emergency Medicine, or as I call it, "Doctors with ADHD!"
i was also going to comment about the colds but i see buckeye beat me to it. i used to joke with students that during an operation with a cold, fluid replacement is not a problem. after all it is a short run from your nostrils, over your upper lip to your mouth.
occasionally i do a tracheostomy in icu. ie. on a normal bed and not a theater table. the patient is much further away. your knees bend almost double to get over him and your back strains. afterwards i'm usually in some degree of pain.
Right. That ICU trach thing is the worst, knee-wise. One of my attendings in training was among the first -- if not the first -- to advocate it, so I did many. More recently, it became outlawed at my hosptial becasue someone (an ENT, probably) got into major bleeding, so the circus of moving to and from the ICU became mandatory. Still, sometimes, when there are enough tubes and lines to make transferring to an OR table even more of a circus, I'd do it in the OR but in the ICU bed. Knees sore, back there.
Several times a week? Was that a typo?
Yessiree, yet another post for my "Sid Files." *achoo*
God bless the nurses that will bring you the oj or the candies, hall cough drops, or a new mask! The longest cases I ever scrubed on were finger/hand replantations, 18+ hours long. Now usually my longest are 3-6 hours these days. In solo practice, I gave up the replants. Too much without a team.
Oh, Jobst makes knee high (male) compressions socks in fashion (black, brown, navy) colors.
After 30 years as an anesthesiologist, I note that I don't have too many client surgeons over 50 who don't have chronic backaches; after patient positioning, I'm pretty fussy (and naggy) about surgeon positioning; looking after the surgeon is, after all, part of a good anesthesiologist's job... I've done lots of neurosurgery in those thirty years, and have Never had a neurosurgeon take a break. They are all crazy that way. I think they just don't notice time passing (flow.) Nice post, Sid. It was real.
Check out some of the UnderArmour socks at your local sporting goods retailer - they don't have graduated compression like the medical type, but they're over-the-calf length, synthetic (no blisters) and have lycra - enough that you can feel the compression on the calf.
I'm surprised nobody has mentioned the usefulness of rigid orthotics - I never thought my feet were the source of problems, but my sports medicine guy/physiatrist made an offhand suggestion and it changed my life.
I have to agree with the pus thing. I've always found draining pus (mostly incisions, bartholins' abscesses, tuboovarian abscesses, etc.) one of the most satisfying parts of my job. It just feels like you've done something really right when you drain and irrigate all of that stuff away.
If I'm in a really interesting case or some big pelvic exenteration where, as a scrub, I am constantly attentive and have a lot going on, I forget about all of my bodily functions. I think my longest may only have been about 6 hours, but as they are closing, I suddenly become famished with hunger or realize that my bladder has been full for a very long time....
Time is a funny concept in the OR - and difficult to explain to people who have never been there. The same 4 hour case can seem like 30 minutes to the attending, 2 hours to the chief resident, 6 hours to the junior, and a lifetime to the medical student. It all depends on how well each individual understands the task at hand and how much control each has regarding getting the problem solved.
You can't concentrate on the task if your own body is fighting against you. If the surgeon is sick or distracted - a cold, the flu, a sore ankle, a poorly fitting headlight, a difficult OR environment - you can hardly wait to get free of the case or deal with the annoyance.
So, you are absolutely correct; surgery IS a thinking person's sport, but the body and the environment both need to cooperate to make the time fly. That's when it's fun.
(By the way, I apologize for all ENT doctors if one of us was the cause for your hospital's hew ICU bedside trach policy.)
Bruce: excellent point about time sense. I'm often amazed at the end of a long case to realize how long it was, when it felt like no time at all. And as you said, the exact opposite was true when I was an intern or student.
Your description of the nurses being so attentive to you (back rubs) brought to mind the book House of God by Samuel Shem. Totally off-topic and unrelated to your post, but I wondered if you'd ever read or commented on that book. I've just finished it - it was....a whirlwind.
PS: Bruce -- apology accepted.
Anon: I've read it. haven't commented here. I liked it, but I know a similar book that's better....
Owie, Sid, all of this hurts. Then buckeye comes along with the kleenex jammed up the nose and the antiviral drugs. I knew plumbers body's were brutalized and often shot by their 40s or 50s, but I never thought about a surgeons. Jeesh.
Very interesting post! I wondered what surgeons do if they're sick - have colds, etc. What about sneezing? Staff must be happy that you all have masks on when someone is sick.
Recently Dr Keagirl stated in her blog something like you know your a surgeon because you have the bladder of an elephant. :)
You all have such unbelievable physical stamina to be able to do the work you do and with needing precision and knowing that one slip and your patient can go south. Talk about pressure and probably a rush at times too. :)
I haven't assisted in any surgeries lately ;) but back when I did more often (mostly c-sections), I noticed that some seem to fly by, moving in the groove, where others which took forever were actually close to the same amount of time. The time dilation problem and the recurrent needlestick problem I had were cured when I stopped scrubbing with the guy I later heard the scrub techs call "scary Larry."
mitch, i'm not used to the concept of an anaesthetist that thinks "looking after the surgeon is, after all, part of a good anesthesiologist's job...". usually there is a feeling of resentment towards surgeons where i come from. you can dope for me anytime.
Do you mean to say that you have hepatitis C? I'm so sorry.
B, actually. Serologically only.
The Nurses and Surgical Technologists have a system for breaking one another out of Surgery that includes a safe transfer with counts, but timing is everything if we are to maintain continuity during a case. It comes down to that basic principal of risk/benefit: does the risk of fatigue and lack of concentration outweigh any potential disturbance to the Surgeon. I always tried to remain on task for the duration of my cases and take a break between Surgeries; this was fine on 6 or even 8hour cases. When any case goes on for 10 to 12hours however, I really do think all of the Surgical team should take it in turns to briefly break scrub.
It is not healthy to go without water, food or urination for 12 hours! In my Blog I have posed the question: “How long is too long for a member of the sterile team to remain continuously scrubbed into surgery without a break?” I would love to get some opinions on this from Surgeons; go to: http://medicintegrity-team.blogspot.com/ I was a Surgical Tech for 5years and I am now in the NIFA program to become a First Surgical Assist. Both roles require high levels of concentration to anticipate the needs of the Surgeon.
Because Hospitals must have a mechanism in place for providing relief to their staff there is no reason for any of us to function way beyond normal endurance levels to the point of impaired performance that might place a patient at risk. Unfortunately, there are powerful financial motivations for Hospitals to cut back on redundancy of staff and that has led to serious abuses of break policy standards due to what I now call “Deliberate Negligent Understaffing.” For me breaks during Surgery are not a luxury to forgo because Hospital Management has made a conscious decision to chronically understaff the OR of a Level One Trauma Center on Saturday nights as a cost cutting measure.
It is the duty of a charge Nurse to guarantee that all of the staff on duty are functioning at their optimum and Management are morally obligated to provide adequate staff coverage. I have launched the Patient Safety Campaign C.U.T! CONTROL UNDERSTAFFING TODAY, to target the Deliberate Negligent Understaffing of US Medical facilities. Surgeons should not have to concern themselves with this understaffing issue, but the safe care of Hospital patients is in crisis due to the “Nursing Exodus” precipitated by top heavy Management. We really need your help to restore the safety of patient care.
As we've corresponded before, the physicality of of surgery--particularly in the early/training years--is one of the biggest drawbacks to jumping in to an otherwise slam-dunk residency decision for me.
Shadowfax's comment, "Fuck it. Let's just close her up and see if she lives." had me howling out loud!
The comment about 2h to the attending, 4h to the resident, etc. was one of the most insightful replies. If a surgical case was mostly the actual ACT of doing the thing, I think it'd be easier to deal with. When a vast majority of the time is getting in there before the fact, and the meticulous sewing after the fact, there's not very much distraction from the aching back or grinding knees, etc. when all you're doing (I say lightly) is throwing down running suture (or the like) for the 10,000th time.
As someone else said, this post was real..no lipstick on this pig.
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