Surgery Week 5 & 6

Surgery Week 5

Monday, August 27, 2007

Today, is my first day on my new surgical service, the Transplant team. Everyone who heard that I was doing Transplant surgery asked me, “WHY???? What did you do to get stuck with that???” Apparently, Transplant surgery has a reputation for being extremely tough. But I’m lucky, today. There is NOTHING going on. For the most part, all I do is sit in the team room and try to read, while meeting everyone.

One thing I did get to do was go on a consult on a lady with an infected AV graft. You see, patients who have constant kidney problems have to go on dialysis. Dialysis involves taking your blood, filtering it, and giving it back to you. This is what your kidneys do all the time.

So in order to make this work easier, a lot of times, they will do a surgical procedure where they connect an artery in your arm with a vein in your arm. This is called an AV Fistula. If you have to use some artificial tubing to connect them, it’s called an AV Graft.

We were called to check this lady’s graft to see if this lady’s graft needed to come out, because she was showing signs of endocarditis (infection of the heart… usually the valves).

Afterwards, I met one of our attendings and our Chief talked about the case with the lady. She is a bad surgical risk, and it looks like a dangerous thing to do. All of a sudden, the attending looked at me and pimped me by asking what are the causes of endocarditis… I was COMPLETELY shocked, because I was under the impression that attendings didn’t really talk to students on this service. But I blurted out, “IV Drug Use, Rheumatic Fever, and Lupus.” Ding Ding Ding! He said, correct… and then also told me about some unusual causes like colon cancer for some reason…

At 5:30, my chief told me to go home. He told me that it was okay to wear scrubs all day on days that we’re not in clinic and that I had 3 kidney transplant procedures the next day!

It was… a great day!

Tuesday, August 28, 2007

Rounds are SO much easier and efficient on Transplant. It’s amazing how well everything works.

Overnight, we had a patient who got a kidney and pancreas transplant. The donor was a young teenage girl who was riding on the back of a truck and the truck hit a bump and she got thrown off the back and hit her head. Lesson learned… don’t ride on the back of a truck.

The other kidney is going to a Ms. LM this afternoon.

But before that transplant, we are taking the kidney from a middle aged son, Mr. EC Jr and transplanting it in his dad, Mr. EC Sr.

I watch the kidney removal, watch the kidney get prepped to be implanted, and then go to watch the kidney get put in.

It’s a really really long process. The attending for the 2^nd case is the head of transplant surgery. He’s pretty intense and scary. He asks me a whole bunch of questions about myself… including whether I was religious… and what religion I was… I obviously answered these questions honestly and openly, but I couldn’t help but wonder… where the heck is this going? Very weird. He asked me a lot of questions about my life story and how I came to med school and what I was interested in doing. I think he thought I had a pretty interesting life story.

It was hard to see a lot for both of these operations… but it was really exciting cool to see the kidney get implanted and go from being whitish gray… to a pretty pink. And then getting to feel the blood as it flows through the artery was really amazing.

Right after that, I scrubbed in to see Ms. LM get her kidney. This time, it was brought in on a special machine that kept preservative and blood flow running through it. It was pretty amazing. I got to watch it taken out of the machine, and prepped. And then… when they had opened up the space in Ms. LM and they were ready for the kidney… I finally got my moment…

Perhaps, I should explain… when I used to work in the ER, I was working a night shift… and around 4 a.m., they called me to the front and asked me to transport a lady in a wheelchair to a room upstairs. As I took her admission packet, I looked down and saw that she was here to get a heart and lung transplant. So I started talking to her about it. And when I dropped her off… I remembered feeling so privileged to be the person that got to take this woman up to get a new lease on life. And as I left the room, I shook her hand and said, “Good luck with your transplant today, ma’am… and congratulations.”

I walked back down that morning feeling so incredibly happy about my job and being so thankful to God for giving me a chance to walk with people in this way.

So back to Transplant surgery… when I assigned myself to Transplant surgery… I was a little reluctant, because it was known for being kind of tough… but the one thing that convinced me to take the hit… was the prospect of possibly being able to deliver the organs for someone getting a transplant… whether it be taking a cooler to the helicopter people… or bringing in a cooler to the OR.

But in the OR, now… I looked up as my attending said to me, “Dr. Lee… would you like to bring us the kidney?”

I said, yes, sir… and walked over to the table and picked up the basin filled with ice and saline solution and the kidney… and carried it over. The Scrub Nurse laughed and said, “Don’t drop it.” Right. Like that thought wasn’t SCREAMING through my head about a million times. And I felt this rush of joy and happiness run through my body as I brought the Kidney to the table… and getting the opportunity to play a small role in giving Ms. LM a brand new quality of life. Everything else after that was a bit of a blur. I got to see the kidney pink up. I got to feel the blood flowing through the vessels. I got to see urine coming through the tubes.

All of that was great. But the most important thing… is that I was able to have the one moment that I was hoping for more than anything.

All in all… I spent 10 hours straight in the OR… with just a chewy granola bar for lunch… My back, feet, calves, and shoulders were KILLING me… I struggled at times JUST to stay awake… they sent me home as soon as the surgeries were done…

Wednesday, August 29, 2007

After 10 straight hours of surgery, I wake up this morning feeling like someone beat me with a baseball bat. Walking in to the hospital, all I can think about is when I get to sit down.

Rounds are a little painful just because I’m so tired… but it’s really satisfying to see that all 3 of our kidney patients are doing well.

After rounds, we have some down time. I am very grateful for it.

Later in the morning, we get a call for a surgical consult on a former transplant patient with a large abscess on the back of his neck. I go to the clinic with the fellow… it’s pretty gross… and the patient has less than desirable personal hygiene…

It looks like he is going to get taken into the OR to get it drained.

That afternoon, we go to clinic. I don’t actually get to do anything… but we see some interesting stuff. One of our patients got an AV Fistula done a while ago and I get to feel and hear it. It’s amazing what these things feel and sound like! Listening to it is like hearing a whirring and whooshing of an ultrasound machine. It’s amazing.

It’s a fairly uneventful day. And quite frankly… I really needed it.

Thursday, August 30, 2007

Thursday mornings, we have Grand Rounds. Grand Rounds is a lecture with all of the residents, interns, and students. It’s usually on a topic that has very little to do with the students. Today’s session is on the hospital’s disaster plan. On our way in, I run in to my old Chief. He’s sitting down and he looks at me and he says out loud to no one in particular, “I miss Kevin.” I laugh and say, sorry. I’m thinking, ha ha ha ha ha!

One of the residents that I was on call with sees me and says, “Hey, are you on call this weekend with me?” When I tell her no, she gets disappointed. It’s cool to know that as a medical student, I am becoming someone that others want to work with. As lost as I feel most of the time, it’s good to know that I am not coming across too terribly confused.

When we get back to the floor, I see Mr. EC Jr walking down the hallway very gingerly. He was the one who donated his kidney to his Dad. He was trying to find his way to his Dad’s room and didn’t know where he was. So I lead him there. And when he walks in, his Dad looks up. And EC Jr says, “Hey pop.” Sr says “Hey. You hurtin’ much son?” And Jr says, “Naah.” And he sits down and the two of them just tap each other’s shoulders. And sit quietly. It’s a simple scene… one that you’d probably see a million times… except for the fact that one son gave his Dad an incredible gift that would dramatically change his Dad’s quality of life. How incredibly cool.

That afternoon, we have D&C (Deaths & Complications). We talk about Mr. WW. It sucks. They talk about this man’s passing and the complications that led to it. It’s so… I don’t know… I don’t have the words to adequately describe it. All I kept thinking was that… this discussion just did not do this man justice.

Friday, August 31, 2007

Today is a pretty busy OR day. My first case is a parathyroidectomy. This is a pretty complicated procedure. And I’m in with a pretty intense doctor. I get asked some questions by my chief before I go in… and I do well. I get asked some questions by the attending… I miss the first one… but then I recover and do pretty well… The operation is pretty tricky. And some stuff goes very badly. And this attending throws these really intense, stressful temper tantrums every time he doesn’t get exactly what he wants. He has me holding retractors for him, and he gets mad at one point and positions my hand a certain way and says, “THIS is how you hold this.” About 5 minutes later, he gets upset because he can’t find what he’s looking for. He looks at my hands and says, “Why are you holding it like that? Hold it like THIS.” Keep in mind… I haven’t MOVED since he positioned me. About 10 minutes later, he gets frustrated and yells at some other folks… then looks at my hands and says, “I told you to hold it like THIS.” Again… I haven’t moved since he positioned me. What a delightful man.

At various times during this operation, I contemplate WHY I am even doing this. I have elaborate fantasies of me just dropping the retractors and walking out of the OR. I picture myself walking down the hill, getting in my car, and driving home to Fairfax. I imagine other things I can be doing for a living… ALL of them involving waking up at 9 or 10 a.m.

Of course… after thinking about all of this… I also remember all of the ways that God brought me to Medical School. And I laugh. He got me through everything up until now… he’ll get me through this.

After 5 hours of this painful cycle of him yelling and throwing temper tantrums, I am exhausted… and all I want to do is drink a gallon of water and eat a gigantic bowl of food. I don’t care what kind… any kind.

I have just enough time to inhale 2 chewy granola bars and then I have to go back into the OR… with the same Doctor. It’s another painful case. The patient is getting a graft removed from her arm. She is at high risk for anesthesia, so instead of putting her to sleep, they do a nerve block on her so that she will not feel any pain. She is also NOT supposed to be able to move her arm… but the docs that did the nerve block didn’t do a good enough job… and even though she can’t feel her arm, she is still moving it. This causes a LOT of stress during the operation. And the disturbing thing is that the Attending is in such a foul mood that he’s YELLING at her to stop moving. It’s really nasty and stressful in there. He’s yelling at an 86 year old woman. I understand how stressful it is for her to be moving her arm… but it’s so unnecessary to be this way.

After 2 hours of this crap, we’re finally done. When I get upstairs, I find out that one of our patients, Mr. DD, who was admitted that morning is looking like he has a serious problem with his liver transplant. He had gotten his transplant 3 weeks ago. And now part of the transplant is leaking in a very bad way. He gets rushed to the OR. In the OR, they discover that one of his arteries is completely blocked. So it caused part of his liver to die off. It’s really stressful in there, because nothing is going right. There are 2 attendings and a fellow that are scrubbed in. I’m over by the wall watching. There is a lot of yelling. I decide it might be best to leave.

Upstairs, we sit in the war room and we talk about the mess of the situation. About an hour passes and the attendings come in. He needs a new liver. The thing is… we actually had a liver that was supposed to go to another patient later that day. So now what do we do? Do we give the new liver to Mr. DD? Or do we give the liver to the person who was supposed to get it? The thing is… it’s not entirely up to us… because there are rules that control these situations. Our attendings put in a formal request to find a way to give the new liver to Mr. DD.

I leave that night not knowing what’s going to happen.

It’s labor day weekend… and I actually have 3 days off. I am going home to NoVa to get some serious sleep and some good food.

My first week of transplant was a weird ride. There was a lot of cool stuff… but some moments when I was absolutely miserable.

Saturday, September 1, 2007

I drove up to NoVa in the morning.

It’s funny how much you get used to living a ridiculous life. Being at home, I couldn’t get over how weird it was being back to a normal life. I didn’t realize how tired I was. I didn’t realize how drained I was. I didn’t realize how much I didn’t want to go back.

It’s good to be home.

Sunday, September 2, 2007

I sleep like a rock and then wake up to go to church. It’s great to see everyone. When I was teaching Sunday School, I would walk through the church in the mornings and get hugged by about a thousand kids ranging from 4 to 20. I miss that. I see one of my favorite girls who jumps up into my arms and kisses me on the cheek. She says she's not letting go until I die. I think everyone needs to hear that from time time.

I also get to spend time with one of the high school kids that I didn’t get to see all summer. We sat down and had time to talk. I realized as I was talking to her that this is where God needed me to be… and she needed to hear what I had to say.

I spend the evening starting to feel relaxed… I spend the evening just talking with my Mom. I don’t want to go back. But I know I can get through the rest of surgery. I just have 4 more days of Transplant Surgery… and then I have Cardiothoracic at the Veterans Hospital. Cardiothoracic is supposed to be very laid back.

So I know that if I can just get through 4 days of Transplant Surgery, I’ll be okay. I’m driving back to Richmond on Monday morning to finish this out.

I think I’m ready.

Surgery Week 6

Tuesday, September 4, 2007

I go back to the hospital feeling well-rested!

I find out that the liver went to Mr. DD and the original person was sent home. I’m told everything went well. And he actually looks great. I still can’t get used to how a patient can be so sick, have their insides opened up… and then later on… look perfectly okay. It’s so weird.

One of our patients who got a Kidney and Pancreas Transplant, Mr. LS is doing so well. He’s mentally not all together. This happens when people get sick. He was so out of it that his nurse walked and found him trying to drink from his own surgical drain. Oh God.

Today is a semi-busy OR day. We have a Kidney Harvest and Transplant today. This particular situation is interesting. This is a “Variance” Donation. “Variance Donation” works like this. Suppose someone wants to donate a kidney to a relative. But they are not a good match. Well that person can instead, donate to the Transplant List anonymously. If they do this, then their relative goes to the top of the list for the next available matching kidney.

Our lady today is doing this… not for a relative… but for a friend… that she met on the internet… Hmmm… a little weird…

She also wants pictures taken of as much stuff as possible… She says she wants to use the pictures to encourage people to donate their kidneys. I wonder if they did a proper Psych evaluation on her…

I watch both the harvest and then the transplant. The attending for the transplant is the scary one. But he actually isn’t too bad today.

Afterwards, I go to watch them put together an AV Fistula. It’s so cool to see them sewing a gigantic vein to an artery.

At the end of the day, I have been on my feet in the OR for 10 hours again. I am so freakin’ tired. Once again, all I get for lunch is 5 minutes with some nutri-grain bars. It’s funny because you get hungry and lightheaded for about an hour… and then after that you’re just too hungry to be hungry.

Still… seeing a kidney turn pink after it’s been implanted? UNBELIEVABLY cool.

Wednesday, September 5, 2007

I am starting to find my groove. I am getting faster at getting stuff done. I’m getting better at being helpful. It’s a great feeling to no longer just feel like extra baggage.

It’s not a SUPER busy day in the OR, but there’s enough to keep me busy.

One of our patients is an 8 month old baby who got a liver transplant at 2 months old. He actually got part of his Mother’s liver. His name is THM. He was born with a disease that causes his blood and liver to hold on to too much iron. It’s usually fatal in babies. He had been doing okay after his transplant, but now he keeps having this weird cycle of developing fevers and watching his Red Blood Cell Count drop. They can’t seem to figure out what’s going on with him, so today, we are doing 3 things. We are putting in a Central Line because they have been having a TOUGH time starting IV’s on him. We’re then doing a liver biopsy and a bone marrow biopsy.

He’s such a cute baby and I feel so bad for him as he lies there unaware of what’s going to happen to him. When they knock him out so that they can intubate him, it is really disturbing to see his limbs just go completely flaccid. Intubation is when they a patient gets a tube put down their throat and just above their lungs so that they can be kept breathing while at the same time knocked completely out. I’ve never seen a kid go from being awake to being intubated before. It’s a little hard to get used to.

The Central Line gets put in. The liver biopsy goes well. It’s time for his bone marrow biopsy. I have sent off many kids to GET a bone marrow biopsy done. I never knew that THIS is how it gets done. It is incredibly BRUTAL to look at. A gigantic needle that looks more like a pointed stake is pushed with a TON of force into the patients hip bone area. Then they use this handle on top to just screw the needle deeper and deeper until they get a good section of bone marrow. It looks UNBELIEVABLY painful.

While we are in the OR, I find out that we have a kidney transplant scheduled for that afternoon. It’s for a nice grandmother named Ms. MH. When I meet her, she spends some time telling me how excited she is to get this kidney. It turns out that because her kidney has been giving her difficulty, she has been on fluid restriction. This means she can only drink so much liquid a day. She tells me the one thing she is looking forward to the most is that she will be able to drink as much as she wants. I am really happy that she is getting a kidney.

Her operation takes 5 hours. I can’t believe how painful it is to just stand. The operation goes well though.

I limp home at the end of the day. I can’t wait to sleep.

Thursday, September 6, 2007

A really uneventful day.

A lot of classes.

Blah.

I think I get MORE tired when I’m not doing anything.

Friday, September 7, 2007

I’m a little excited about today. First off… it’s my last day of Transplant Surgery! Woo Hoo! Second off… I’m going to get to see my first laparascopic operation! That’s when they stick these cameras into the belly and use special instruments to do what needs to get done. It’s cool because it makes it easier for the person to recover.

I am going to see a person’s gall bladder get taken out, followed by a liver biopsy (sampling of the tissue for testing), and an RFA. An RFA is where a special probe is inserted into an area and high frequency radio waves are transmitted in order to kill cancer cells.

My Chief pimps me before we start, but I nail the questions without any problem. The surgery itself is pretty cool. And it’s with one of the nicer attendings. When the surgery is done, the attending leaves and it’s just me and my Chief. There are about 5 incisions to suture up. My Chief lets me suture up 2 of them. They look great. I know it. He knows it. He’s impressed. It feels GREAT to be able to do some stuff.

The next surgery is an AV Graft. My Chief and I start off without the attending. He lets me Bovie, which is the electrical scalpel. It’s so freakin’ cool. And unlike LAST time, my lenses aren’t fogged up and I can see without any problem. It feels great to finally get to do some stuff.

There were 2 kidney transplants that were done overnight. The kidneys came from a person who had Hepatitis C and they are going to 2 patients with Hepatitis C. One of the recipients also has HIV. Here’s the problem though. Neither of them is producing any urine. This is a HUGE problem.

On top of that, 1 patient is having trouble getting rid of their Potassium, which is potentially damaging to the heart.

The other patient is getting dialysis since she is unable to urinate. During dialysis she develops terrible pain and numbness in her right hand. She doesn’t have a pulse in her right hand and when we get an ultrasound, we see that 1 of the 2 main arteries that supply the hand is completely blocked. The other one is almost completely blocked. Normally we would give her blood thinners. But the problem is… she JUST got a kidney transplant. She can’t get blood thinners. No one seems to know what we’re going to do. As it gets to the end of the day, I am feeling very glad that this is my last day of transplant. I get the feeling that things are going to get bad.

When they decide to send me home, they tell me that I did a good job on the service. It feels great to get the compliment… but even better just to know that I’m done… and I survived.

Transplant Surgery wasn’t necessarily as bad as Surg Onc. There was one attending that was incredibly intense. But everyone else was really nice and fun to work with. The surgeries were REALLY long. I’ve learned that I can go a long time without peeing, drinking, or eating. I’ve learned that it just might be possible for a person to sleep standing up. I’ve learned that the simple act of standing is BRUTAL on your feet and back.

All of this is going through my head as I head home… and I realize that I was a little anxious when I was in NoVa for Labor Day weekend. I was afraid that I was going to be in more uncomfortable situations with my attendings. I was afraid of how I was going to handle the long surgeries. But everything went well this week. That’s when it hit me… getting through this week as well as I did... wasn't an accident... someone was praying for me this week. And I knew who it was.

I called home and I thanked my Mom. She asked me how I knew. I told her I just did. I thank her and my Dad. And I tell them that I love them.

It was a good week.

Sunday, September 9, 2007

I’m on call today. When I get there, I find out that one of my friends who was on at night is still down there in the middle of a call. I go to relieve her and find out that she wants to hang out and suture the patient up, because she’s never had the chance to do so. As she gets ready, she suddenly realizes… she doesn’t know what she’s doing. And the residents are busy doing some other stuff. So I decide to talk her through it. And it’s so cool, because I realize how much I’ve learned. Both she and the residents comment on how good a teacher I am. It’s a cool moment.

We get a call that comes in later that day. It’s a guy who was in a car accident and was unconscious and not breathing and didn’t have a heartbeat. One of the other guys on call decides to take it. So I stand back and watch. There’s a nursing student there as well. When the guy is brought in, they are doing CPR on him. I stand back and watch with the nursing student and this nurse that comes in from another floor. I explain to her everything they are doing and why. They ask me a bunch of questions and I sit there and explain why we don’t do certain things, what kinds of injuries you worry about in these situations. It’s really cool. I can’t believe how much I know at this point. Then the nurse looks down at my ID and says… “wait a minute… you’re just a student!” And I say, yes, ma’am. And she asks me how I know all of this… and I tell her I just do… and that I used to work in an ER before. She asks me if I’m going into Emergency Medicine… I tell her I’m not… and she can’t believe it.

The guy didn’t make it. But in a situation like this… they almost never do. When a person is in a trauma and their heart and lungs stop without any obvious injuries on the surface… it’s never good. When they used the handheld ultrasound on him, he basically had a ton of blood just filling his chest cavity and abdomen. He never had a chance.

That’s the only call of the day really. So we spend the rest of the day just studying. It’s a great and relaxing way to transition out of Transplant. I can’t believe it’s been 6 weeks since I started! Where does the time go?

My next rotation is Cardiothoracic at the VA. I’ve heard this is a cool rotation. And that the people are really laid back. I’m really looking forward to a laid back rotation.