Puella cum Cultello

girl with a knife – the tired ramblings of a female surgeon-in-training

Tag: firsts

Words (not) to live by

See one, do one, teach one.

It’s an old phrase in medicine, and it embodies a teaching philosophy that has been passed on for decades – observe, practice, then pass on the skill.  During my third year medicine rotation, that expression was turned on its head once or twice.

Do one, see one, teach one.

I was asked to access a chemotherapy portacath – despite not having seen a port or the needles inserted into them.  The intern dictated a list of supplies and told me the requisite steps, along with a couple of technical tips (namely, “it’s a big-ass needle, don’t stick yourself!”).  I scurried off to the supply closet, eager to get started.

In many institutions, physicians are responsible only for placing central access catheters, which go into the large vessels of the neck and chest.  Specialized nurses will place difficult IVs or peripherally inserted central catheters, and they also access ports.  This allows these nurses to gain experience and develop immense skill in a small range of tasks.  They truly become specialists, and they are far more proficient with those tasks than most physicians.  However, this hospital didn’t have an IV therapy team, union contracts prevented nurses from dealing with most vascular access in a timely fashion, and these issues fell to the already overworked house-staff.

So, here I was, a medical student with less than a year of clinical experience.  I was about to stick a large bore needle into a patient’s chest, aiming for a small device that carried silicone tubing straight into the heart.  I had no frame of reference, no prior experience, for what I was doing.  I had some understanding of the potential complications (infection, thrombosis, air embolism), but the intern didn’t review them formally with me.

Yet no one questioned the appropriateness of this situation.

My intern was happy to have another task checked off his seemingly endless to-do list.  The nurse was glad to have vascular access in her patient without doing it herself.  I was excited to actually be allowed to do something, anything (“I get to touch patients!”), though I definitely had some trepidation about the matter.  And the patient was eager to just have the whole ordeal over with.

Of course, I struggled a little.  I improvised a lot.  I kept hearing a voice in the back of my head – “fake it till you make it”.  And, eventually, both the patient and I survived the procedure relatively unscathed.

But would this situation be acceptable to me as a patient?  Absolutely not.  However, the hierarchy of medicine and my eagerness to be helpful prevented me from insisting on more appropriate conditions.  I was too chicken to refuse, for fear of stirring up trouble, delaying patient care, and losing future opportunities.

Every doctor has to learn, and we all start with very little knowledge.  We slowly gain knowledge and experience under supervision, an apprenticeship if you will, before we’re left to our own devices.  But this should happen in a stepwise fashion, with incremental increases in latitude and responsibility.  Instead, all too often, it’s haphazard, and junior trainees are left to sink or swim – along with their patients.

… but I did stay at a Holiday Inn Express!

There’s a first time for everything.  But no one wants to be the first patient for anything.  And I can’t blame them – I wouldn’t want to be a guinea pig for someone’s first attempt at drawing blood or removing an appendix.  Still, all those doctors and nurses you see walking around the hospital had to learn somewhere.  If you’re in any kind of teaching hospital, chances are they’ll be learning on you.

To be sure, there’s plenty of supervision, whether from attendings or more experienced residents.  That supervision is usually most direct in the summer, when newly minted doctors are being unleashed on the unsuspecting masses for the first time.  Still it’s considered very poor form to make it obvious to a patient that they’re your first.

Less than a week into my residency, I was asked by an attending to perform a fairly routine bedside procedure – changing a negative pressure wound therapy (aka wound VAC) dressing.  The dressing itself consists of a sponge which is cut to size and placed in the wound, then covered by a sheet of sticky clear plastic, the “drape”.  An attachment connects the dressing to a pump, and this applies constant suction to the sponge.

Once the pump is turned on, the vacuum effect of this contraption pulls fluid and other crud (yes, that’s the technical term) out of the wound.  It also draws the edges of the wound together.  Together, these effects help large wounds heal much more quickly.  Changing the dressings isn’t too difficult, but there is an art to doing it well – minimizing the patient’s discomfort when the old dressing is removed, cutting the sponge and drape to the right size, creating a proper seal, resisting the urge to fling the pump across the room when it won’t stop beeping because there’s an imperceptible leak somewhere in the system…  Usually, it’s a two person job, since we’re trying to customize and apply a flat dressing to curved surfaces.

Anyway, after some discussion with the attending, he was comfortable with allowing me to change the VAC dressing alone for the first time – I had done a few in medical school with resident supervision, and we had placed the current dressing together in the OR just two days before.  So, I ordered the supplies and went to Mr. H’s room to tell him about our plan.  We talked about the process of changing the dressing, and I told him that once the supplies arrived, we could proceed.  I asked if he had any questions before I left.

“Yeah Doc, are you going to do it or should I expect someone else?”

“I’ll be coming back to do it, your nurse will page me once the supplies get here.”

“Oh good, that’s a relief!  I’m so glad they’re having an expert do it.  I was so afraid they’d send up someone new who doesn’t know anything!”

Smile and nod, girlwithaknife, smile and nod – and don’t say anything stupid.

“Oh, we wouldn’t do that to you Mr. H, it’ll be just fine.  See you in a little while, bye for now!”

With that, I turned on my heel and skedaddled before he could ask any more awkward questions (or realize that he was, in fact, getting a complete noob).

Lord of the Foleys

A foley catheter is a piece of tubing with a balloon on the end.  The balloon goes into the bladder before being inflated, allowing urine to drain into a bag.  They certainly aren’t fun to have, and I imagine they’re about as uncomfortable as they sound.  That said, sticking tubes into people’s privates is sure to result in awkward humor sometimes – right?  Here’s two you might… well, enjoy is perhaps not the right word…

When we get trauma patients, we have to get a urine sample from them.  In some hospitals, they allow the patient to try to pee before putting in a foley, though people often complain about trying to pee on command.  During a med school rotation, we had an especially big weenie of a patient.  He was a 6′ tall, 200lb former marine who had shrapnel in his lungs from his combat time.  Yet, he screamed like a 5 year old when we took his blood.

By the time we got to the urine collecting stage, my poor ears had been robbed of their remaining shreds of innocence.  None of the residents relished the idea of trying to put a catheter into this guy.  Finally, one of them stepped up and explained the options.  His eyes got wider and wider as he heard about the foley.  I don’t think I’ve seen someone reach for a urinal so eagerly before…

Foleys also come in different sizes.  After my first experience putting one into an awake patient, I’ll remember that fact forever.  We had an inebriated, uncooperative patient, and it was clear that he wouldn’t be coordinated enough to give us a sample voluntarily.  The resident asked me to grab a foley set and insert it while she and the ER tech held the patient down.

Foley catheters are measured in French gauge scale, where 12 fr = 4 mm, 14 fr = 4.7, 16 fr = 5.3mm, and 18 fr = 6mm.  In this particular hospital, we almost exclusively used 14fr or 16 fr catheters, and they’re placed on a tray near the bed before the ambulance even arrives.  But on this occasion, for some reason, the tray wasn’t ready.  Once again, I had to go hunting.

Finally, I found a foley set in the supply cupboard and prepared to insert it.  I managed to get about 5cm of the catheter into the patient before he opened his eyes with a yelp and tried to leap off the gurney.  The resident and tech managed to hold him down, and they yelled “keep going!” in unison.

Once our adventure in insertion was complete, we continued the rest of our treatment.  As we were cleaning up, a nurse wandered by and looked at the packaging for the foley.

“Why did you guys put in an 18 fr?”

The resident, tech and I looked at each other.

“Whoops!”

Surgeon Humor, episode 2

I still remember the first time I told a joke in the OR.  I was a junior resident, working with one of our most “old school” surgeons, Dr. D.  He’s renowned for being extremely meticulous, and he doesn’t suffer fools gladly.  If you’re operating with him, you have to be prepared.  He’s also very formal – sometimes, I wonder if he even knows any residents’ first names, because he makes it a point to always address us as “Dr. Lastname“.

We were performing an extremely complex case, an operation that Dr. D is known for internationally.  I was positioned to his left and slightly behind him, holding onto a retractor.  My most important tasks during this case were to provide perfect tension for several hours and to stay awake enough to answer any questions he might ask.  I was doing pretty well so far.  Until Dr. D turned very slightly towards me and said in his usual stern tone, “Dr. Girlwithaknife.”

Ah crap, he’s gonna ask me something and probably I won’t know the answer and then I’ll look like an idiot…

“Yes, Dr. D?”

“Do you know any good jokes?”

Uh, think… wait… jokes?!

“Um… yes?”

“Good.  Would you care to share one with us?”

Oh God, think!  Of course, my mind went completely blank.  Well, except for one slightly off-color joke.  Nooooooo!  I can’t tell that one!

“Um, well… ahem… Ah.”  *deep breath*  “Well, you see Dr. D, the only one that’s coming to mind right now is, um, perhaps not appropriate for sharing in mixed company.”

He turned all the way around and looked at me with a raised eyebrow, “I see.”  Then he went back to operating.  Okay…  And then he turned back towards me, “Well?!”

Great.  There was no getting out of this.  I’d have to tell the joke and live with the consequences.  Do or die.  God knew what Dr. D would think of me now… and hopefully no one else would decide that I was somehow harassing them.

“OK…  And if anyone gets offended, I apologize in advance!”

Awesome preface, that only ensured that everyone was looking at me with curiosity.

An elderly couple were discussing their wills.  The husband turned to his wife and said, “My dear, if you were to pass before me, would you mind if I married a beautiful young woman?  It would ensure that my final years would be happy, even without you at my side.”  The wife thought for a few moments.  “Well, darling, I suppose I wouldn’t mind too much.  But you’d have to agree that if you pass first, I could find myself a handsome young man to enjoy my final years with.  After all, 20 goes into 80 much more easily than 80 goes into 20.”

There was slightly a terrifying moment of quiet while everyone processed the punchline.  Then –

“Ahahahahaha!”  Dr. D’s booming laugh filled the room.

And I could finally sigh with relief, hoping that my cheeks would stop burning before the end of the case.

Code Blue

Because I could not stop for Death,
He kindly stopped for me;
The carriage held but just ourselves
And Immortality.
-Emily Dickinson

In medicine, we confront death on a daily basis.  It’s been 8 years since I started medical school, but for me, it remains sad, terrifying, poignant, brutal.

The first code I participated in was all of these and more.  I was on call on a Saturday evening with another 3rd year medical student, W. It had been a slow day, and we were just hanging around, studying, chatting, and waiting for 6pm.  W had taken a short break while I continued reading, but she’d been gone for a while.  I decided to give her a call.

While we’d been separated, she had been drawn into a “code blue” on the fifth floor.  This was was where ventilator-dependent patients, among our sickest, were placed – never a good sign.  I raced up the stairs before W could tell me the room number.  I knew that when I reached the ward, the crowd that assembles at every code would lead me to the correct place.

I no longer remember the patient’s name, or even what she looked like.  But I do remember that she was a young woman, diagnosed with an aggressive cancer while her children were still in need of mothering.  Even though her condition was terminal, her husband had insisted that everything possible be done for her.  Death had been looming for weeks, but he wanted their children to have their mother for every possible second, no matter how incapacitated she might be.  She’d spent the last few days alive but unable to interact with them in any meaningful way.  On this quiet weekend afternoon, with none of her family nearby, her body was finally giving up.

She was one of my first lessons in clinical detachment.  During this code, she wasn’t a wife or a mother anymore, she was just another patient, one we were trying to keep alive at her family’s behest.  We knew that we were fighting a losing battle, even if her husband had refused to accept the limits of our abilities.

A couple of residents were taking turns pumping her veins full of medication and pounding on her chest, the respiratory therapist was trying to keep pushing air through her tracheostomy, and W was standing in a corner, holding up an IV bag and looking as though she hadn’t yet decided whether to cry or vomit.

I caught our resident’s attention and asked what I could do.  I became the designated equipment runner, a task complicated by the fact that I was unfamiliar with this floor and couldn’t get into any of the locked supply rooms.  I proved far more adept at relieving W from her imitation of an IV pole.

The code went from bad to worse.  The patient’s heart wasn’t responding to medications, chest compressions, or electrical shocks.  The pumping of the ambu-bag was frequently interrupted by attempts to clear the secretions which were plugging up her trachea.  Blood-tinged froth bubbled from her mouth and nose.  Her pulse was thready despite the fluid and medications we were giving, and her blood pressure was too low for our monitors to detect.

Finally, after 40 minutes of this, the attending running the code allowed us to admit that we had lost this round: “I’m going to call this one. Everyone agree?”  She named the major team members one-by-one, making sure that there was consensus, that we had done all we could.

As the techs, nurses, and residents filed out, W and I stayed.  The attending taught us the steps of confirming brain death: the patient was totally unresponsive; she didn’t have any brainstem reflexes; there were no breath sounds.  We were instructed to ignore the slight fluttering of eyelids before her dull eyes were hidden – it was merely a sign of residual electrical activity in her peripheral nervous system, not an attempt to show us she was still clinging to this world.

Neither W nor I were sure to say or do next.  We’d seen dead people before, from the cadavers in anatomy lab to the autopsies in pathology.  We’d met hundreds of patients already.  But today, for the first time, we had watched someone die.

No lecture, no group project, no role-playing session prepares you for that moment.

So, we reverted to helpful medical student mode and tried to assist with the clean up, using damp towels to wash the body of a woman we had never known while she was alive.  The nurses would then tidy the rest of the room to allow her family to say their final goodbyes.

After wiping the last of the blood from her face, we covered her limp, broken body with a clean sheet, as though concealing our collective defeat.

She was finally at peace.  We were not.