Surgery Week 4

Sunday, August 19, 2007

I’m on call tonight. That means I have to stay at the hospital from 7 p.m. until the next morning… and then continue to work through the hospital day. It’s a long night. We keep getting trauma calls that we have to go down to. There doesn’t end up being a lot to do with each trauma that comes in, but we all have to report to each one anyway. I get about 2 hrs of sleep. And then it’s time to go to work…

Monday, August 20, 2007

It’s 5:30 a.m. and I’m getting ready for rounds. I feel kind of nauseous because I’m so sleepy. I slept about 2 hrs total, but not in a row. It’s amazing what happens to your brain when it’s sleep deprived. We start rounds and my Chief is in a bad mood. Rounds are even more disorganized than normal. I get to see Mr. JC and do his dressing. And I’m so happy to see how good it looks. I look forward to seeing Mr. WW because I want to know how he’s feeling, but we don’t go to see him today… which is a bit odd.

Rounds are over and it’s time for the OR. I’m only supposed to be in 2 surgeries today. But my first case is with a pretty intense doctor. I’m a little worried, because I don’t know how I’ll do. The surgery is the removal of a benign lump in the breast, which is weird, because we don’t usually remove lumps from the breast unless there’s something wrong with it. There wasn’t a lot of information about this surgery in any of the records, so I didn’t really understand why we were doing it. So of course, when we start, he asks me why are we doing this surgery today. And I’m honest with him, by saying, I know we’re removing a lump from her breast that’s benign, but I don’t really understand why. So he asks me how I would go about evaluating a person who came in with a breast lump. I go through the entire workup I would do and what tests I would do. In the end, I come back to the same conclusion… I’m not really sure why we’re doing this. So he asks me, “So am I an idiot? Am I completely wrong for doing this?” I tell him, “ I don’t think so, sir… but I don’t know why.” And he laughs and tells me that my answers were completely right… the only reason we’re doing it, is because she wanted it out. I almost laugh out loud with relief, but I just keep it to myself. The funny thing is, when we take out this lipoma, which is just a fancy word for fatty tumor, it actually looks… kind of pretty. Strange thing to say, don’t you think? I mean it’s smooth, perfectly encapsulated… pinkish with swirls… it looks very very pretty… Strange how mother nature works… things that are harmless look really good when you take them out… cancer just LOOKS really bad when you take it out.

But during the surgery, the doctor and my chief are talking… and I find out why we didn’t see Mr. WW today… He passed away over the weekend. I feel my heart sink right there in the OR. I’ve seen a lot of death in my life. I’m not naïve. I know Mr. WW had a really bad prognosis. I just feel awful knowing that I was part of the team that was taking care of him and yet we couldn’t figure out what was wrong with him in time to help him. I remember that on Saturday, he was complaining about not being able to breathe. Well… it turns out… he died of respiratory failure… And that just makes me sick. When I find out the details of how he passed, I feel even worse. And I don’t care to share them. Even as I write this down, I feel my eyes well up and my heart hurt just knowing that I couldn’t help him. Even worse… I’m angry that no one on the surgical team was willing to sit down and talk to us about it. I’m angry that no one decided to help us to come to terms with his passing.

We have an attending session in the afternoon. Once again, it’s an intense session where we get asked questions as we talk about mechanical ventilators. This is NORMALLY tough even under normal conditions… being sleep deprived makes it about a million times worse. I can’t even think.

When we’re done, we figure they already had afternoon rounds and we’ll be able to go home. But no. Of course not. We have to freakin’ hang around and wait for rounds to start… then we start rounding and we serve absolutely ZERO purpose. Then all of a sudden our chief just disappears. So we have to go back to the break room and wait. At 7 freakin’ p.m. we finally leave. I go home and pretty much just go straight to sleep.

Tuesday, August 21, 2007

I wake up at 4 a.m. feeling like someone beat the crap out of me. I’m so glad that we aren’t in the OR today, because I think I would fall asleep standing up if all I were doing were standing there.

During rounds, I still can’t get over Mr. WW.

Today is conference. Conference is usually when the interns and residents get asked a bunch of questions. But for some reason today, we, the students, get asked questions. They start talking about PET scans, and they ask us if we even know what a PET scan is. I tell them yes, and they look at me, and say, oh really? Well what is it then? I totally nail the answer. The response I get is, “that’s exactly right.” It’s absolutely stupid that this should make me happy… but it does.

After conference, we have clinic. I brought M & M’s for the nurses today. They are very pleased with me. During afternoon clinic, I see Ms. DW waiting in the lobby. I go out to say hello. She’s the patient that I got to do the incision on. I love seeing her, because she’s a cool lady and because she is the first and probably only patient that I ever got to do an incision on. I actually take her drain out for her today. Of course, I have everyone hovering over me as if I’m an idiot. You just have to tolerate it. But I feel cool doing it.

Towards the end of afternoon clinic, I had a really amazing experience. I was about to see a patient, when one of the surgeons stopped me and told me she had a job for me. It was weird, because there were other med students around, but for some reason, she came to me. She said she wanted me to go upstairs to the Pediatric floor to do a surgical consult. Now, here’s the thing. A surgical consult is when a surgeon is called in to evaluate a patient to see if they need and/or can tolerate surgery. This is not a job that is given to medical students. It’s usually given to an intern. I am incredibly honored. She gives me the name of the patient, and I recognize the name as a surgery that I was in on before. We took out a lymph node from his armpit to evaluate him for cancer. I actually got to sew up his surgical incision. When I tell the surgeon, that I was in on his surgery, she gets excited and says, “Great! That’s even better!” So at least I know that she didn’t give this job to me for that reason, seeing as how she forgot that I was in on it. I have no idea how to go about doing this special job… but I wasn’t about to pass it off to anyone.

When I get upstairs to the Peds floor, I find that CH isn’t there. He’s at Radiology getting fit for a special mask for future treatments. I don’t know what I should do. I sit there feeling kind of unsure of myself… when I notice on the board… the name of a very special patient I used to work with. Her name is SD. I used to work with her when I volunteered at the Peds Onc Clinic. She has bone cancer and I first started working with her when she lost her leg. She wasn’t very talkative back then and I didn’t blame her. This beautiful girl had every right to be upset that she had to lose her leg. This was probably the first kid with cancer that brought me to tears just by looking at her. She became my most special patient here at MCV. Whenever she was admitted to the hospital, I would go visit her. I’d mostly just play cards or sit with her while she watched movies. We didn’t talk much, but we had a good rapport. We always looked at each other behind people’s backs and rolled our eyes at how goofy people could be. It was cool. I was with her on her last day of hospital chemo. I was so happy for her.

Well, sometime after that, she relapsed. I wasn’t part of the hospital system, so I couldn’t really go visit her. And I felt awful not knowing what was going on with her. So seeing her name on the board was an absolute Godsend. So I went in to see her. And we had a great chat. She was so much more talkative than when we knew each other before. It turns out she’s relapsed a 2^nd time. I know what this means. I know that her chance for survival isn’t good. And I understand that this is probably part of the reason our paths crossed again. I know that this is one of the things that God has called me to do. I know that I connect with kids that are terminal in a way that is unique. And I know that God brought us together again so that I can walk with her during this particular part of her journey.

When I was done chatting with her, I came outside… and CH was back. Coincidence? Yeah, right.

When I went in to see CH, my heart sank. When I saw him 2 weeks ago, you could easily see and feel swollen lymph nodes all over him. Now, the swelling around his neck was so bad that his neck looked like a bullfrog. This is not a good thing. For his lymph nodes to grow that much in such a short period of time does not predict good things. I did the consult and wrote down as efficient yet thorough note as I could. When I present it to my senior resident, he tells me he’s impressed.

I didn’t leave the hospital until 7 again that night… but somehow, I felt good about the day.

Wednesday, August 22, 2007

Rounds are getting worse and worse. I hate them. The only bright spot to the day is when I got change Mr. JC’s dressing. He is reading a children’s story bible. I ask him what story he’s reading and he says, the story of how Jesus fed the many. I smile and say, “5 fishes and 2 loaves, sir. 5 fishes and 2 loaves.” He laughs and asks if I’m a Christian. I tell him, “Yes, sir. I absolutely am.” And I tell him that my favorite story in the Bible is the story of Joseph. I find it for him and watch as he starts reading with that look of wonder that only children get. And I think how much God must love that despite all of his suffering, Mr. JC still has the faith and innocence of a young child. I think of all of those people out there that are better educated… and I laugh at the wisdom Mr. JC has in comparison.

It’s an OR day. I’m not in many surgeries today. My first surgery is a tumor excision from the leg with the head of surgery. When I go in to talk to my patient, I see someone from anesthesia trying to start an IV on her. For some reason she looks familiar, and I realize that I had seen her around the hospital up at INOVA Fairfax. I ask her if she used to work there and it turns out she did. She was a nurse up there and she’s in Nurse Anesthesiology school now. It seems like a small thing… but at this school… it’s always nice to meet another Korean! Whenever I get a free moment that day, we chat about Korean food and NoVa. Anyway…

The surgery itself is pretty cool because we actually take part of the inner thigh muscle with it. And as they cut the section of muscle away with the electric scalpel, the muscle twitches… keep in mind, this makes perfect sense, because the electric cautery is passing electricity through the tissue. But it still looks cool.

When we’re done, I have to keep an eye out for CH who is my next surgery. I did the consult on CH, and basically he’s just getting a special line put in that will allow him to get chemo without getting stuck all of the time. But this morning, his blood isn’t clotting right, so he can’t get operated on until they give him a transfusion. So I bounce back and forth between looking at the computer, going to the Peds floor, paging the interns with update, and checking the OR schedule. Over the course of the day, I probably walk about 15 miles going back and forth. During one of the times I’m upstairs, I see SD again on the Peds floor. We exchange email addresses and I’m so happy that we are reconnected.

At 3 p.m. I finally get CH ready to go to the OR. When we get to Pre-op, his Mom says she’s glad I’m going to be in the OR with him. Of course, that’s when I get paged. We’re having teaching rounds. I ask the surgeon what I should do. She tells me I need to go to teaching rounds. I’m so upset, I can’t even explain. I spent the whole day trying to get this kid in for his operation. And his Mom tells me she’s glad I’m going to be in the OR. And now I can’t go in. When I get to teaching rounds… I find out… big surprise… that we have to wait. An hour passes and I am getting bitter. When all of a sudden… I find out that teaching rounds are canceled… and we’re just doing regular rounds. I get so mad I think I’m going to punch something. My friends try to cheer me up, but I’m upset.

To make matters worse, Mr. JC has been sent home. As we stand in his empty room, my chief laughs and says that when someone has been in the hospital for this long, when they finally go home, they are usually back within 48 hours or they die. And he laughs. At this point, I am inconsolably angry. We’re in the hallway as my chief goes to a different room and I start talking to my friends about how this is why I hate surgery as a profession. The callousness that forms about anyone other than themselves. I’m all but shaking, I’m so pissed. When we get to the Pre-op/Post-op area to Round on some post-operative patients from the day, I decide I’m not going to round anymore. I go out to the waiting room where I know CH’s Mom is probably waiting for his operation to be over. And we sit and talk for a bit. It’s a great conversation and I know that she needed it. Of course this is how God’s plan always unfolds, right? I wanted to be in the OR. But obviously, I was more needed in the waiting room with his Mom. And my anger and outrage were what put me there rather than just rounding as normal.

But of course, all of this great perspective doesn’t come until a while afterwards. I leave the hospital at 7 still seething mad.

Thursday, August 23, 2007

When I get to the hospital, we have a little time. I’m sitting at the nurses’ station and I ask the night secretary for something. I know it’s kind of a pain in the butt and I feel bad, so I ask, “Ha ha… are you going to miss us when we’re gone?” And she says, yes. I ask her if she’s serious and she says, “You all are one of the nicest crews we’ve ever had come through here.” It’s such an unexpected compliment. It makes me momentarily, very happy.

But then we have to Round. And Rounds – suck.

But after Rounds… we get 2 hours for breakfast with no residents around!

I had a brilliant idea right before I went to sleep and my conversation with the night secretary confirms it. So before I eat, I get cards for the nurses at the clinic, the nurses on the floor, and the staff of surg onc and make sure we all sign it.

After breakfast, we have our last attending session and it’s pretty cool, because we get to talk about whatever we want.

Afterwards, when we go to clinic and give them their card, they tell us that we’re the first group that has ever gotten them a thank you card. How ridiculous is that? I can’t believe that as much as these nurses teach us, not one student ever thought to get them a card. It just shows you why people don’t like med students.

I see an interesting patient at clinic. He has cancer under his thumbnail. It’s one of those things I never really knew about before I started this rotation. And just the fact that I understood it without him having to tell me anything more made me realize how much I have learned in this past month.

The afternoon is pretty much a waste of time. It’s our classroom sessions. They are BRUTALLY difficult to stay awake for.

We have rounds afterwards. I hate rounds. We get out of the hospital at 6:30.

Friday, August 24, 2007

It’s our LAST day of Surg Onc! I’m doing everything I can to make sure we don’t get in trouble.

Rounds are AWFUL.

But I do my best by running ahead and making sure the bedside chart is ready. My chief is in a foul mood… but everyone else has an early surgery today… so I have to stay with him the whole time… when we’re done, I tell him I’m going to go change and go to the OR. He says okay… and then… he says, “Thanks for running ahead and making sure rounds ran smoother.” I was FLOORED. To actually get compliments!

In pre-op, I find out that my chief is going to be in my first surgery with me. So when our patient gets there, I page him. When he sees me… he thanks me for paging him! I’m wondering if he’s hurt or if he’s drunk or something. And I realize… he actually is going to miss us…

Surgery is brutal. The operation is pretty simple… but the attending surgeon is yelling and screaming at the chief for almost the entire operation. The attending asks me a few questions, but I nail everything he asks me. When the attending leaves and it’s just me and my chief closing up, we have a pretty decent conversation. My chief thinks I should consider doing something more than just Peds. It’s a pretty big compliment I think.

After that case is done, my last case is a hernia repair on a patient that I examined my first week on Surg Onc. It’s supposed to start at 11:45, but the surgeon is held up in another surgery. So we have to wait until she’s done. We don’t go into the OR until 1:30. And the surgery ends up being kind of complicated. She actually starts having some blood pressure and heart issues during the surgery itself. It’s funny because we have these sterile drapes that divide us from anesthesiology. And it’s like there are 2 totally different worlds sitting there with that patient. Our side has part of the patient open and that area is all you see, whether it be an abdomen, breast, or arm. The other side has just the head and a WHOLE bunch of machines and tubes that are controlling her heart, lungs, and her fluids. So we’re just sitting there, calmly doing our operation, when all of a sudden, about 8 doctors and nurse anesthesists come in to the room by the head of the table. We actually have to stop the operation for a little bit, until they can get everything under control.

We don’t finish until 5:30. I almost pass out from hunger and tiredness. I think it’s an appropriate way to finish the rotation.

When I go back to the floor, I find the other students just sitting around and waiting for rounds. Everyone else on General surgery is done and home. We have to wait of course. It sucks. Our chief comes in at 6 and says, we can go. Our friend, Katie says, “Oh, but we wanted so much to round.” After a split second of terror on our end, our chief starts laughing! As soon as we hit the stairwell, our fists are pumping, I fall to my knees.

I can’t believe we survived our month of Surg Onc. It was a brutal experience in many ways. But I learned so much. I feel so much smarter than I did when I started. I still have another month of surgery left… but nothing will be as hard as this past month has been. So glad it’s over.

Friday night, I go out to Liver Rounds, which is a gathering of students from all 4 years at a local bar. It’s so funny because first years are so happy and excited and… yes… clueless. I am happy to see many of my 2^nd year friends… but it’s hard for them to really understand what I’ve just gone through… I’m annoyed at any of the 3^rd years that do NOT have surgery… because I know that no matter what THEY may think or say, those of us on surgery had it so much worse than they did…

I am only really happy to see my fellow surgery students… We survived a month of ridiculous hours and much aggravation.

But as happy as I am and as much as I want to celebrate… I’m pooped by 9 p.m. PLUS, I’m on call the next day. So I’m home by 9:15… asleep by 9:30. What a party animal I am.

Saturday, August 25, 2007

It’s 7 a.m. and I am officially on trauma call.

Basically when you’re on call, you’re MAIN responsibility is to respond anytime a trauma comes into the ER. A trauma is when someone is hurt in an accident or attack of some sort that may involve potentially life-threatening or permanently disabling injury.

It’s a busy day. My first call involves a guy that got hit by a car while he was on his motorcycle.

My second call is a guy that got beaten up and thrown down the stairs.

I get a moment to chill out and I decide to go see CH, the kid that I worked on getting into the OR on Wednesday. He’s doing well. He looks great. And we chat for a little bit about little league baseball.

On the way back, I decide to check on my last surgery patient. She’s still in the ICU and she’s sleeping or unconscious. I figure it’s best to just leave her be.

I think about visiting one of our old patients, Mr. AB in a different ICU… but he’s on contact precautions, which means I would have to put on some protective gear just to go in to see him. I decide against it… and instead choose to have coffee. As I’m in the cafeteria, putting my coffee together, I see Mr. AB’s family walk in. And they immediately come to talk to me. How bizarre is that??? We chat for a while and they are able to vent to me about how frustrated they are and how difficult things have been. All I can do is tell them I wish there was something more we could do. But I also tell them that in my estimation… he’s due for a good week. I tell them that he’s had some crappy weeks… and it’s about time he had a good one. They brighten up when I say this… and I feel a little better. I can’t help but be amazed at how these work… There I was… feeling the pull to go in there… and in the end… it worked out better that I had a chance to talk to the family instead.

After coffee, the calls come in again.

I go down for a call and as I’m waiting for it to arrive, we get this guy that walks in off of the street. He got stabbed in the neck 3 times. As we’re working on him, we get a guy that comes in after running a marathon. He finished the race and on his way home, he passes out or something and runs his car into the siderails on I-95.

I get a quick break after these calls, when I get paged again. I get down there and I find out we’ve got a gunshot victim coming in. Well it turns out there are 2 of them. The first guy comes in and they figure out that he’s very much dead. They declare him dead within 1 minute.

We start working on the next guy and he’s still awake, but very much woozy and out of it. They have a big thing of gauze on his groin area and they tell me to hold pressure on it to try to stop the bleeding. The thing is… he’s in really bad shape. And as I’m sitting there holding pressure, they have to crack open his chest. Keep in mind, I can NOT move, because if I let go, he’s likely to bleed all over the place. So I’m just sitting there watching as they cut through skin, muscle, and fascia, and then spread the ribs apart. And there it is… his heart and his lungs moving all around for me to see. It is UNBELIEVABLE.

They get to work and they end up having to shock his heart using internal paddles. I can’t believe that I am actually seeing this just 2 feet away from me as I’m holding gauze over his groin.

They end up getting his heart back under control and the next thing I know we’re moving him to the OR. When we get to the OR, there are so many people involved that I don’t even scrub in. I just try to help out and then just watch. They are trying frantically to stop him from bleeding out. It is crazy to see what I am seeing. While we are there, another trauma call comes through. So the intern and the resident leave, and they tell me to scrub in with the trauma attending and the chief. I’m sitting there holding retractors and watching the heart and lung moving around. I cannot describe how amazing it is to see the human heart and lungs working from the inside.

But no matter what they do, they cannot get his heart and lungs to work on their own. And they have to declare him dead. Once they do, they let me put my hands in and do cardiac massage, so that I can feel what a human heart really feels like. I am in awe. I can’t believe that this man’s tragic circumstances are providing me a window of education that I couldn’t possible get otherwise. I am so humbled by the incredible privilege of being able to be a part of this journey. As we close him up and I feel his skin get colder and colder, I realize how suddenly death can overtake us. I realize how quickly life can end. Just 1 hour ago, this man was awake. Just 2 hours ago, this man was alive. And now, I was trying to help the surgeon sew his chest back together so that his loved ones wouldn’t have to see him like this. I don’t have the words to put all of this into perspective. Not without sounding trite.

When we finish up, I realize that the legs of my scrubs are covered in his blood. I go to change and am happy to see that it is 7:15. I am done for the day.

My last week of my surgical oncology month was certainly out of the ordinary. I can’t believe a month has gone by… but I am also very glad… I am tired. I am in severe sleep deficit. I am finding mail in the kitchen. I am finding books in the refrigerator. I am having trouble remembering if I did things I’m supposed to. I don’t remember what day it is most of the time. And I have a hard time remembering what life was like before surgery. I can’t sit for more than 30 minutes without getting sleepy.

But I’m halfway done with surgery. And I know I have learned a TON.

But more importantly… I still have a smile on my face… because I know this is where I’m supposed to be… even if surgery isn’t what I want to do… every day I see something that I know will make me a better doctor… and every day I get a chance to interact with a patient in a way that I know is helping them.

And when you look at it from that perspective… sleep is a small sacrifice to have to make.

I still wish I could get more of it though…