As promised

Surgery stories, straight from the front lines:

-I have mixed feelings about laparoscopic surgery. Sure, the patient has faster healing times, smaller scars, and all-around feels better, but the surgeon doesn't get to touch any blood or guts. Where's the fun in that?
-Surgeons suck. Not all of them, of course, but by and large, they fit their stereotype: arrogant, self-absorbed, and rude to anyone who isn't a surgeon. If you pretend you want to be a surgeon when you grow up, you'll be treated well; if you tell them you want to be a pediatrician, well, I hope you have thick skin. Hell, if you even tell a general surgeon that you want to be a different kind of surgeon -- ENT, orthopedics, Ob/Gyn -- you'll still get made fun of.
-Surgery residents suck. Not all of them, of course, but by and large, they fit their stereotype: overworked, under-rested, with very little time to teach the students but plenty of time to scut them out. Not cool. Plus, they're all REALLY jaded.
-Working 90 hours a week is definitely not cool. I really don't know how I survived. It makes me really not look forward to residency.

-Obese people should try to avoid needing to have surgery, because they don't heal well. I know this causes a dilemma for the obese person who wants to have bariatric surgery... but I would still counsel against it, as the medical student who has to take care of you afterward. I saw so many post-op patients with infected abdominal incisions, it was disgusting. One of the solutions to an infected wound is a wound vac, which is a device that creates a vacuum environment in the wound -- you put foam in the cavity, attach it to a tube, seal the whole thing down with a sticky plastic, attach the tube to a vacuum device, and turn it on. The negative pressure promotes wound healing, sucks away all the nastiness (which is collected in the device), and when you change the foam, you pull it away from the new tissue, which allows for micro-debridement.

Well, my #1 most notable wound vac experience involved changing one for a woman who was about a month out from her gastric bypass surgery and now had wound healing issues. She wasn't a particularly whiny patient in general, but come wound vac time, I was told she was a piece of work. So I worked with the nurse to make sure she was maximally medicated -- 8 mg of morphine and 2 percocet should do the trick. Right off the bat, she was a mess. Whimpering in anticipation as I carefully peeled away the sticky plastic, grimacing and grabbing my arm to make me stop periodically, taking off that sheet of plastic took a good 15 minutes alone. Then it was time for removing the foam from her 5" deep abdominal cavity (YUCK!). For those of you without an appreciation of this, let me explain. Her wound was entirely within the fat layer of her abdomen -- before you reach the ab muscles or the guts inside. So contract your abs, then push your finger into your abdomen and note how deep you have to push before you hit your tensed muscles. I guarantee you have way less than 5 inches of fat padding your belly. Anyway, back to the story: I explained to the patient that this was going to be like a band-aid -- 1, 2, 3, and pull. Yes, it would hurt, but it would be over quickly. She wasn't going to have any of it. She wanted me to pour sterile saline all over the foam to soak it so it wouldn't hurt as it pulled away (thereby defeating any debridement effect) and to pull it way ever so slowly, millimeter by millimeter. Give me a break. With every tiny tug of the foam, she sobbed. "Oh my god, I'm going to pass out from the pain!" she would scream. "Please, god, let her pass out," I thought to myself. Oh yeah, I forgot to mention that the wound cavity was not only 5" deep, but about 8" long and 4" wide. This took a while -- 1 hour, to be exact. Every few minutes she would bargain with me to pause -- "just for a moment, let me catch my breath!" -- during which time I would surreptitiously pull a little more (I'm so bad, I know).

At one point, she asked me how long I was on duty. I told her I was going to be there all night (it was already 11:30 pm at this point) and she responded, "Good. So you can take your time doing this." Bitch. "Well, yes," I responded sweetly, "but in 4 hours I'll have been awake for 24 hours, so do you really want me doing this sleep-deprived?" In my head, I was cursing the possibility that she would keep me awake for the next 4 hours and I wouldn't get to have any sleep that night.

At another point, a commercial on the TV in her room came on for -- wait, you'll love the irony -- lap banding. "Ask your doctor how lap banding can help you lose weight," the woman intoned as I delved deeper into the blood-and-pus-filled cavity that was this woman's abdominal wound that was a direct result of bariatric surgery. I seriously could have punched a hole through the TV at that point.

Finally, after an hour and a half, it was over. I was trying really hard, but I had no more patience for this woman who (sorry, jaded moment here) had been the cause of her own disease (morbid obesity), had not taken care of herself post-operatively, thereby helping the incision to not heal, and had driven me to wits' end with her complaining while I was trying to help her. And those are the days it's really hard to be a doctor-in-training.

-Another patient that is going to stick with me was a woman I started taking care of a few days after emergency bowel surgery. Almost all of her small bowel had become ischemic and died (an anatomical abnormality combined with a clotting disorder), and they had had to remove it. Now she was on TPN (nutrition through an IV), and was waiting to be discharged to a recovery facility, but no nursing home would take her (an insurance issue, I think). So she was diligently walking the halls, trying to regain her strength so she could go home. She was learning all about her TPN and her various tubes and drains so she could take care of them herself. She was the nicest woman in the world, with a 4-year-old miracle baby at home (she was 44 years old), and she wanted to go home. She wasn't a candidate for small bowel transplant, since her liver still worked -- they were going to give her TPN until her liver gave out, then put her on the list for both a liver and small bowel transplant (the world is cruel that way sometimes). I'm not sure why, but we missed our window for discharge -- someone wanted to keep her in the hospital just one more day for something -- and then the next time we looked at her abdominal incision, it looked icky. Hospitals are not good places to recuperate, people; they're full of bugs and germs and your goal should be to not get put in one, or to get out as quickly as possible. Over the next week, her incision opened up, she showed lots of signs of infection, and then she threw a small clot into her lungs. She was put in the ICU, and everything went downhill. I think as of today she's still alive, but no one thinks she's going to make it. It's really sad, because she was doing everything right, and I think the system failed her.

On a more happy note, I spent my last week of surgery shadowing a private practice ENT, and I saw the coolest thing: cerumen (ear wax) removal. All these people have ear canals FULL of earwax, and the ENT would use a tiny scraping tool to pull it out. It was amazing -- out would come these GIANT chunks of ear wax, all nasty and yellow-ish brown and black. And the patient would exclaim, "Wow, I can hear so much better now!" It was satisfying medicine at its best. And now I really, really, really want to see the insides of my own ears somehow.

There are more surgery stories, but right now, after a restful 10 hours of sleep, I can't remember any of them. I'm having a wonderful time on my week off, and I'm not going to ruin it anymore by reminiscing about the worst 8 weeks of my life :)

On Monday I start pediatrics. I hear the hours are awesome, the residents are friendly, and the kids are cute. Of course, the parents are another story, but I am determined to be patient. Unless I run into any anti-vaccine parents. And on that note, here's the latest story from that front: Parents use religion to avoid vaccines. Um, what's up with that pediatrician telling her patients to lie?