Cut to Cure (23/30)

     Before starting my surgical rotation, I was both very excited, and very nervous. I knew from my time in Kenya that I enjoyed observing and assisting with surgeries, so I was looking forward to the chance to do it again. Plus, it's a rare thing in medicine to be able to cure a patient's problem with one procedure, but this is a real possibility in surgery. If a person's issue is an inflamed and infected appendix, we can just take it out. Boom. Problem solved. However, I knew from my women's health rotation that surgery can also be stressful, and I was all too aware that we had not spent much time covering suturing and surgical knot tying in lab during my didactic years, so I was a bit terrified of screwing something up. I also wasn't too thrilled about the ice box ORs (60 or 62 degrees was the norm) or long days (shifts were could be as short as 8 hours, but typically lasted 12-14 hours, depending on how many operations were scheduled) or all the procedures that hadn't been covered in depth during didactic ("treatment: surgery" doesn't cut it as an answer when you're actually in the surgery),  but I prepared myself to try to learn as fast as possible. There was definitely much to learn.

From Medcomic

     One thing I learned right away on the surgical rotation is that, in surgery, more than in any other of my rotations, the hierarchy and divisions of medicine are clear. As a student (whether PA or MD), you are at the bottom of the totem pole. Above you are attendings, PAs, NPs, residents, interns, nurses, and basically everyone else. When you're actually in the OR, there are even more people, like the anesthesiologist or nurse anesthetist, circulating nurse, and, of course, the scrub tech or scrub nurse (a quick note on the scrub tech/nurse: you do not mess with them. You give their table a wide berth, you follow all their commands, and if they say you broke sterile field, whether or not you think you did, you had better apologize, make it right, and then promise never to do it again. Some scrubs are nice and friendly and will ease you into everything if you seem unsure. Others will watch you for signs of weakness and will put the fear of God into you if they sense you have the potential to screw something up, which is necessary since a patient's life could be on the line. You just have to figure out how to live and learn with both, and focus on doing the best you can do.).  In short, there are a million people who can, and likely will, order you around. That's part of being a student, just like coming in at 5AM to do pre-rounds before actual rounds, or having the freakish 24+ hours overnight shift. Some students hated this, but everyone had to deal with it. 

     Beyond the hierarchy, I also learned to recognize the other divisions in the medical fields, specifically the divisions between providers who chose to go into surgical specialties, and those who chose to go into medical (aka non-surgical) specialties. Anyone who has watched the TV show "Scrubs" knows that the surgical people (typically portrayed in green scrubs) are known as the jocks, and the medical people (typically portrayed in blue scrubs) are known as the nerds. This is a stereotype actually perpetuated in real life as many of the surgeons would jokingly refer to themselves as "dumb surgeons" who just knew how to take things out of people. Obviously, this was a gross misrepresentation, but it was funny to actually hear them say it. It was even funnier to hear the general surgeons talk about the orthopedic surgeons, because the general surgeons often referred to their compatriots in orthopedics as being the true "jocks" of medicine. However, I will admit that it is true that orthopedic surgery is in a different class from general surgery.

The Todd... jock surgeon extraordinaire

Orthopedic surgery sometimes felt like a workout as I stood there holding up a limb for what seemed like an interminable time (fact: unless you look like a pathetic weakling, this is the student's job and, fact: whether it's an arm or a leg, they get very heavy, very quickly, especially when you can only support them with one hand lest you accidentally touch a sterile area while not yet scrubbed in yourself), and it is also more violent then general surgery. There is truly elegance to any surgery, and sometimes I loved simply watching the surgeons as they deftly made incisions, tied off vessels, etc., all while making it seem like a dance. The dance is just rougher in orthopedic surgery. It's hard not to be when a typical set up for an orthopedic procedure includes mallets and saws. Yes. Mallets and saws. I enjoyed scrubbing in for any surgery, but I am not sure I'll go into orthopedic surgery in the future as I have learned that the sound of bone crunching kind of freaks me out. Go figure. 

Expressed calcium deposit.
Image can be found here.

     In case I wasn't sure before, this rotation reminded me that it's ok to have fun in surgery. I could give multiple examples of this, but the one that comes to mind right now is from my time in orthopedic surgery. There was a patient with shoulder pain because calcium deposits had built up in the tendons of their rotator cuff, and they needed to be removed. We did that by inserting a camera, finding the deposits, making a small hole, expressing (aka squeezing out) the deposits, and then stitching up the hole. It turned out that this procedure is surprisingly satisfying and entertaining. This might weird some people out, but it's a bit like squeezing a zit, only you're squeezing out calcium deposits (which can either be hard as a rock or more like toothpaste) rather than pus, and there's much more to squeeze out. During the surgery I observed, nurses from other rooms came to tell my room to quiet down because everyone was laughing too much and getting too excited whenever we found another deposit. It was very, very weird, yet also very fun. I guess you could say I learned to embrace the weirdness. 

The coffees of my overnight shift

     I talked in a previous post about how much of clinical rotations is just learning to be flexible. This is another part of the weirdness, especially as you have to learn to handle a schedule that changes daily. My schedule for this rotation was divided into four sections, each lasting just over a week. These sections were general surgery (primarily gastrointestinal surgeries, each time with a different surgeon), orthopedic surgery (we found out our assigned surgeries in the morning on the way to the OR), orthopedic office (each day was spent seeing patients in the office of a different orthopedic surgeon), and general surgery office, which I actually spent in the weight loss clinic. This last section involved the unexpected realization that there's quite a bit of psychiatry in surgery, at least in bariatric surgery. I'm not sure about other weight loss clinics, but if someone wanted to have bariatric surgery done at my site, they were required to meet not just with the surgeon, but also with a nutritionist/dietician and psychiatric nurse, as well as attend meetings held by other people who had undergone the surgery. The goal was to make sure that the surgical candidates were really prepared for the operation, that they understood what life changes the operation required, and that they would actually be able to stick to those changes. I learned that it is possible for someone to "fail" a gastric bypass or gastric sleeve (i.e. still gain weight), and that there were good indicators of who those patients would be. Specifically, any patient suffering from an uncontrolled psychiatric illness was told to wait on their operation until they were mentally healthy, patients who had been obese since childhood did worse, and patients were reminded over and over how important it was that their family supported their decision since the lack of encouragement (or even downright enabling of bad habits) from family members was often a major deciding factor in whether or not a bariatric surgery had the desired long-term effects. On that note, patients were also counseled that their family not only had an effect on them, but that they also had an effect on their families. Overweight parents in particular were reminded that much (some might even argue most or all) of a person's future eating habits are set by the time they turn 8, and thus the importance of developing healthy eating habits in children could not be overemphasized. If you want to see a video that makes this point in a vivid way, I present this ad: 

     On the subject of making life choices, I should mention that I was tempted to title this post "Lose Weight, Stop Smoking, and Exercise: Primary Care Part 2" because it seemed like much of my rotation was simply spent dealing with the consequences of people ignoring the advice of their primary care doctors. Orthopedic surgeons would lose much of their business if people were not carrying around extra weight that wore and pounded on their joints. Cardiac surgeons would have less to do if people exercised and kept their hearts fit. All surgeons would have easier jobs if people just stopped smoking because (contrary to the popular notion that smoking just affects your lungs) smoking affects every organ system in the body. I have a post on smoking in the works because it comes up so frequently, but right now I'd like to mention one aspect of smoking closely tied to this rotation: there are surgeons who will refuse to perform surgery on a smoker, and they have good reason for this. Smoking causes narrowing of the small blood vessels all throughout the body (vasoconstriction), which means that those vessels are no longer delivering much needed nutrients and oxygen. After a surgery, this can mean an increase in both healing times and failure rates for the procedures. Now if a patient comes in with acute appendicitis and they need an appendectomy before the appendix ruptures, of course they will get the surgery, whether or not they are a smoker. For more elective or less emergent procedures though, there's a good chance that surgeons will require that patients quit before they'll operate. Orthopedic, cosmetic, and bariatric surgeons in particular are strict about this, and some will even test their patients for nicotine before the operation to ensure that the patient has been compliant. So please, just quit smoking now. Soapbox over (for now).

Some advice for PA students preparing for their surgical rotation:

Knot tying on my overnight.

• Sometimes residents bribe you with chips and a cookie to stay late and assist with a surgery. This is completely ok. Take the food and eat it while you can.
• This follows the last point, but please eat. You might have very weird hours, but grab at least a snack, even if it isn't a full meal, between surgeries because you do not want to pass out in the middle of a surgery. That being said, if you do feel light-headed in the OR, tell someone ASAP.
• If you know ahead of time what surgeries you'll be assisting with, look them up the night before and become very familiar with the anatomy you'll be seeing. 
• Practice your suturing and knot-tying whenever you can. Keep string on your keys, your steering wheel, your scrubs, wherever. 
• Be flexible. Different rotations are set up differently, but chances are good that there will be a lot of uncertainty. You might work with a different surgeon each day (or even each case), or surgeries might run late or be added on, or complications might arise intraoperatively. No matter what happens, you have to be prepared to roll with it.
• Embrace the experience. Even if you hate surgery, this might be your only chance to actually see the inside of a person while they're still alive, or to cure a problem with a single procedure. You can acknowledge the difficult aspects of the rotation, but take time to recognize the incredible things you are witnessing and enjoy them. 
• Always go with your patient to the recovery room. You should also introduce yourself to them before procedures.
• Realize that sometimes you will feel like an idiot. Some surgeons are jerks. Some residents enjoy hazing. Sometimes people just don't explain everything and yes, there really is a purpose to you rubbing a woman's breast for 5 minutes while everyone else leaves.* You just have to do your best, ask questions when you don't understand, and not let the jerks get to you. 
• Surgeons like to quote the saying, "all bleeding stops eventually." This is 100% true. It is also 100% terrifying. Bodies are complicated, and everyone is a bit different, so chances are good that, no matter how careful everyone is, at some point during your surgical rotation an artery or vein will accidentally be nicked. The most important thing is to remain calm. If you can take a deep breath and continue retracting, or whatever it is you are supposed to do, this will allow the surgeon to find and fix the bleeding vessel that much sooner, and a crisis can be averted. 

Elf ears happen

• Surgical caps can make your ears point out and turn you into an elf. Deal with that, or settle for the silly bouffant. It's your choice.
• Keep the safety of the patient foremost. If a patient has a penicillin allergy, yet you hear the anesthesiologist say they're going to give prophylactic cefazolin, speak up. You might have misunderstood about the patient's allergy, or the anesthesiologist might have missed it, but no one will fault you for double-checking, especially if you do it respectfully. You should also make sure the patient is safe on the operating table, especially in the times right before and after the procedure when they're half-conscious and possibly not always surrounded by nurses and doctors. I saw big patients who we had to make sure didn't drop or roll off the table, and I helped with another patient who tried to fight his way off the table as the anesthesia was wearing off. 
• Know GI! My rotation was predominantly GI and ortho, and I think that's pretty typical. Any neurosurgery usually has to be done as an elective, OB/GYN surgery is saved for the women's health rotation, and most thoracic surgery is reserved for students who know that's what they want to go into, so it's not typically an option for the general clinical year.
• Enjoy the scrubs. Scrubs are basically professional pajamas and they are wonderful. Your surgery (and possibly ED) rotation might be the only time you get to wear scrubs during the clinical year, and you might never wear them again unless you go into surgery or emergency medicine, so enjoy them while you can. 

     In case anyone is still bummed by the dire consequences of poor eating* or smoking (and also just because I love Scrubs), I have decided to close this post with this cheerful gif and video compilation to celebrate the beautiful friendship that is JD and Turk.

via GIPHY

*I had to do this before a breast lumpectomy and biopsy. The resident had injected blue dye that we hoped would drain to the sentinel lymph node so we'd know which node to remove. Even though I was pretty sure I knew why I was doing it and that it was actually an important part of the procedure, it still felt very weird to be massaging an unconscious woman's breast while everyone else left the room to scrub in. 

*When we talked to patients about simple ways to lose weight, the doctor I was with always shared the same four principles: 1. Don't drink your calories (i.e. cut out sodas, iced coffees, cocktails, etc.). 2. Have protein in all your meals and eat it first. 3. Don't eat processed foods (i.e. go for whole foods and avoid junk foods, even the healthy-sounding crackers). 4. Don't skip meals. Another thing that also came up all the time was that exercise is great for improving the health of your body as a whole, but the deciding factor in losing weight is simply eating fewer calories. In fact, many times people GAIN weight when they exercise, not because (as so many people believe) they are gaining muscle, but because they use their exercise to justify eating more, and they end up consuming more calories than they burned. The more you know.