Puella cum Cultello

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

Tag: surgery

Waking up slowly

When I first saw her in the trauma ICU, she was posturing.

B was a college student who had been on a skiing vacation with her family when she lost control and broke her leg.  She was taken to a hospital closer to the mountain, where her fracture was repaired.  Unfortunately, she’d suffered from fat embolism during the operation.  Fatty marrow from inside the bone had entered her bloodstream, eventually becoming lodged in her brain.  When she wouldn’t wake up, her family asked for her to be transferred to our specialist trauma center.

For the first few days she was with us, B showed very few signs of improvement.  Her parents were at her side every day, and during our rounds, they would insist that she was progressing.  I didn’t see it though.  When we examined her, she would grimace and extend her arms – decerebrate posturing, a sign that her brain was massively damaged.  Patients with this type of response to stimulation typically don’t do well.

But our attending, Dr. D, remained optimistic.  He said it was too soon to tell.  Patients with fat embolism tended to do very well in the long-term, he insisted to a skeptical crowd of residents.  He sent us articles to back up his claims, but I still couldn’t believe that B would ever wake up, let alone return to any kind of normal life.

After about a week of this, B was physically well enough to be sent to a regular hospital ward.  She was still quite unresponsive, but Dr. D was unflappable – “Give her a little more time – you’ll see.”

Some weeks and many patients later, I was getting ready to move on to my next rotation.  I was chatting with G, one of the trauma coordinators.  She knows me quite well, so she knows which patients bother me the most.

“So, girlwithaknife, remember B?  She’s going home soon!”

“Really?  To rehab?”  I assumed she’d be sent somewhere for traumatic brain injury.

“Nope, she woke up, she’s done her rehab, and she’ll be going home-home.”

“No way!”  Just a few weeks ago, I was convinced that she’d remain in a permanent vegetative state.

Later that afternoon, I found some time to duck out of the ICU.  I walked over to the rehab unit and found B’s room.  I knocked and heard her voice for the first time, weeks after first meeting her.

“Come in.”

The girl who I thought would never return to independent life was sitting up in a chair with her healing leg propped up.  She was awake, alert and oriented – and serenely buttering a slice of toast.

I introduced myself and sat down.  She apologized for not remembering me.  I could only shake my head and chuckle at her words.  I still couldn’t believe she was awake.  We had a brief conversation before I had to leave her room and return to work.

I left feeling oddly settled.  I was wrong, Dr. D was right.  And I couldn’t have been happier about that.

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.

Surgeon Humor, episode 1

There’s two major rules to OR humor.

1.  Get as close to “the line” as possible without crossing it.

2.  Never pass up a good opportunity to rag on another surgeon.

Basically, you can let your inner 14 year-old out, to a certain extent.  I definitely have an inner 14 year-old, but I don’t let her out too often.  When I do, it can be surprising to my attendings because, well, I don’t exactly remind anyone of The Todd.

We were doing a laparoscopic case on this particular day.  That involves using small incisions through which we place a camera and longer than normal instruments.  We can watch what we’re doing on a video screen, and the instruments let us reach into some pretty tight corners.  It’s kind of like playing video games but on a living person.

Well, I was driving the camera and Dr. R was having trouble getting into some of the far reaches of this patient.  Every few minutes, he’d sigh in mock frustration, pull out his instrument and grumble to the surgical tech.

“Ugh, can’t reach it.”

“Nope, this one’s not long enough either.”

“Dammit, still can’t get in there.”

Finally, he pulled his instrument out and waved it in front of me.  “See, this is the problem, it’s just not long enough, it’s never long enough!”

I couldn’t hold myself back any longer.

“T.M.I., Dr. R, T.M.I.!” *badum tish*

He fell into a stunned silence, while the surgical tech, anesthesiologist, and I all snickered.  Thankfully, he was still grinning under his mask.  Phew!

Though interestingly enough, he did stop complaining about length after that…

The Art of Surgery

Much has been written about the art of medicine and how important the humanities are to our work.  Abraham Varghese has a TED talk in which he explores the art of the doctor-patient relationship far more eloquently than I could.  I’d encourage everyone to watch if they can.  I’ll stick to what I know instead – surgery.

Much of the vernacular of surgery seems dramatic in origin.  It’s no accident that operating rooms were originally called “theaters”.  In Thomas Eakins’ oil painting The Agnew Clinic, the good surgeon and his entourage occupy center stage with their patient.  They are surrounded by rows of seated observers, an audience of medical students whose expressions range from curious to horrified to bored.  Dr. Agnew, dressed in his surgical whites rather than street clothes, has just performed a mastectomy.  He’s no doubt pontificating to the students while his assistants finish the case.

Perhaps we surgeons are just performance artists?  Well, we no longer operate in theaters, though observation opportunities do still exist.  Let’s consider a hypothetical case.

The patient has been prepared in the peri-operative area – he has signed the consent, changed from his own clothes into a hospital issued gown, and an IV line has been placed.  He’s subject and audience of this play – he’s bought his ticket, changed into his costume, and been through the prosthetics department.  Now he’s about to leave the wings.

He’s wheeled into the operating theatre  room and positioned in the center of the OR, under a canopy of dimmed lights.  The anesthesiologist guides him to the twilight zone, where he will remain unconscious, paralyzed, amnesic.  The surgeon and her assistants then position him – an arm tucked here, legs propped up there,  a pillow under the head, as though he is a sculptor’s flaccid model.

Their subject positioned, the surgeons leave temporarily to complete their scrubbing, allowing the nurse to clean the patient’s skin.  The nurse and tech cover him  in blue drapes, marking out the sterile zone, exposing only what is necessary.  The lights are turned on and focused onto the operative field.  The patient is no longer visible, he’s been reduced to a slab of exposed abdomen.

By now, the surgeons have marched back into the room.  They form a line, with the attending surgeon first, followed by a senior resident, then a lowly intern.  Once their hands are dry, the scrub tech helps dress the lead surgeon for her performance, first one arm, then the other, finally tossing the rest of the gown over her shoulders.  The resident surgeons are left to gown themselves.  As the nurse ties their gowns from behind, the scrub tech helps each surgeon with their gloves.   “Shall we dance?” asks the attending, before pirouetting with the nurse to complete the wrapping of her gown.

The surgeons approach the patient, a troop of masked players, anonymous except for their eyes.  They adjust the lights while the scrub tech brings his table full of props closer.  There’s a brief pause to review the plan, spelling out the program for the day.

“Knife please.”  And with a flourish of the scalpel, the performance finally begins.

OK, perhaps I’m being overly dramatic.  We accept that for a successful, clean operation, patients need to be anesthetized, positioned, cleaned, and draped before an operation, while their surgeons must scrub, gown, and glove.  But do these rituals serve a need beyond their technical purposes?  While a well-established routine certainly helps us to remember all these steps, I would argue that it also prepares us for the bizarre acts that are to follow.

If you were to see a surgeon walking down the street, would you know?  After all, this is someone who enjoys using potentially lethal instruments to disassemble and reassemble other people’s bodies on a daily basis – the bodies of patients who have willingly agreed to allow strangers to drug and cut them.  What happens in an operating room everyday is far from normal.  In any setting outside healthcare, it might constitute assault and battery at best, torture at worst.  How could anyone willingly participate in this?

The ritual, being “on stage” and performing in costume, allows us to assume roles outside our ordinary selves, overcoming the limits of what we see as natural or normal.

The patient dresses for his part and becomes a willing subject.  He’s about to allow strangers to make him lose consciousness before they break his skin – but it’s OK, the rites of preparing for surgery have marked him as a patient rather than a victim.  In a hospital gown and with an IV in his arm, he’s here to be cured, not killed.

Once scrubbed, gowned and gloved, I’m no longer girlwithaknife,  I’m now Dr. girlwithaknife.  I’m no evil torturer, I’m the surgeon to whom this patient has entrusted his health and given his permission to operate.  I can allow myself to press a scalpel into another living person’s skin without fear, because he needs my skill.

So, we may not be performance artists – but for a surgery to succeed, every person in the room needs to fill a role that goes far beyond the ordinary.  And perhaps our funny costumes help us do that.

Heartbreak Hotel

Residency can be lonely, with long hours that make isolation from friends and family inevitable.  Often, during that separation from our own social supports, we’re left to care for people in terrible situations.  This piece was written several years ago, while I was working nights in the ICU, right around Thanksgiving.  Reading it again has brought back a flood of emotions.

……………………………………………………………………………..

Over the last few weeks, I’ve been taking care of a very sick woman, D.  She had 2 prior bouts of cancer, and then developed a third, more malignant form in her upper esophagus this year.  Her tumor grew so large, so rapidly, that she could no longer swallow her saliva.  Our attending agreed to remove the cancer and reconnect her esophagus, with the understanding that this would be a palliative procedure, not a curative one.

She underwent a technically challenging but successful procedure involving two surgeons, and several residents.  Unfortunately, when D woke up, she couldn’t move one side of her body – she’d suffered a stroke during the operation.  We couldn’t treat the stroke because it was caused by a blood clot deep in her brain – using a clot busting drug would turn it into a bleeding stroke, one that we’d be unable to control.

By the following day, D had another blood clot, this time in her leg.  Because we couldn’t use any clot busting medications, she went back to the operating room to remove this blockage.  Most of the blood clot was removed, but the smaller blood vessels below her knee remained closed off.  She was left with considerable pain from both surgeries and her mottled leg.  Further testing showed that she had a disorder of excess clotting, one that was quite rare and not routinely tested for.

During all of this, the blood supply to D’s new esophageal connection was also compromised, damaging the delicate tissue that had been so painstakingly re-attached.  We had no way of knowing this until foul smelling liquid began to ooze from her incision.  Upon further investigation, we found a gangrenous esophagus.  From a medical perspective, this was essentially irreparable.  There was nothing we could do to significantly prolong her life.  Her underlying condition was incurable, and in her current state she wouldn’t survive long.

Our attending tried, in the best way he knew how, to convey that to D’s twin sister, the only family member still alive.  He repeated it over and over… D had a clotting disorder that no one could have known about before the operation.  The same process that happened in her head and in her leg had happened in her neck and damaged the esophagus.

To our medical minds, this meant that the graft was dead, well beyond repair, just like her brain and leg.  To her twin, it meant that there was still hope.  After all, she also had clots to the brain and leg – those were damaged but still alive.  She could survive this too, right?

Everyday, the attending would repeat the same phrases.  And everyday, the well twin would nod and smile bravely and tell us that D was a fighter.  We soon began to wonder when she’d finally put her sister in hospice, end this futility.  As the time dragged on, I slowly realized that it wasn’t false hope – this woman wasn’t in denial, she simply didn’t understand what we were trying to tell her.

Finally, the night before Thanksgiving, the well twin approached me in the hall.  I was in the middle of transfusing blood for another patient who was bleeding it out almost as quickly as I was putting it in.

Doctor, that graft… is it ever going to work?

Oh no, I cringed internally.  Not this question, not now.  But as I looked at her, I couldn’t just walk away.  She needed to know, to understand.

So, I answered her truthfully.  As I spoke, I could see the hope in her eyes fading.  The esophageal tissue was dead.  In the best of circumstances, we might have been able to perform an even more complex salvage operation.  In this case, with D’s body already so badly compromised, the salvage operation would likely kill her faster.  I tried to be as plain as possible and as gentle as I could be.  The words sunk in and her tears welled up.  All I could do was put my arm around her shoulders and wait for her questions.

But I just didn’t have time to comfort her.  I had to leave, my pager calling me to other tasks, other patients, other disasters.  I spent the next couple of hours distracted as I worked, hoping I hadn’t just destroyed the well twin too.  When I finally saw her again, she thanked me, for telling the whole truth, helping her understand.  But it didn’t feel like I had done much, certainly not enough to deserve thanks.  Then she told me her plan for D.

They would spend Thanksgiving, the next day, together – just as they had for over 60 years, as a family, as they only family they each had left.  The decisions would come after that.  I think we both knew the decision had already been made.  And all I could do was hug her again.

Later that night, a photograph on the bulletin board caught my eye.  It was part of a display explaining the benefits of an “open” ICU.  The well twin was shown asleep, in a chair beside her sister’s bed.  All you could see of D was a hand, extended over the side of the bed.  Even in the middle of the night, sleeping in an ICU room hundreds of miles from home, the twins were inseparable, hand in hand.  Yesterday, they went home together, to allow D to die at home.

And I stood there again tonight, alone, staring at that picture.

Welcome to my office

This is a place for me to keep a journal as I resume my surgical training after some research time.  It’s certainly been an interesting experience so far – a mix of humor (often dark), anger, frustration, accomplishment, exhaustion, pain, upheaval, learning, absurdity, loneliness, and, occasionally, sheer terror.  I think I’ve grown a lot so far, but I’m sure there’s more to come.

Because I’ll be writing about real-life healthcare encounters, I’ll sometimes change the details of a story to preserve the privacy of patients – as well as myself and other staff.  However, I’ll be as honest as possible about my thoughts and feelings about the situations I see.  As a former English major, I’m sometimes prone to extensive edits and melodrama… you’ve been warned!