My last week in Sacramento, in addition to trying to pack and get everything back in my car, I was sent follow a resident in the Emergency Department. This service is especially difficult because its patients range from the mentally agitated to those in car accidents. While the interns may only have to cut away clothing, someone must be ready to open the patient. The cases I saw, in quick succession, give a hint of the diversity one resident had to deal with the same evening.
Case number one: an adult male, previously treated for injuries sustained when he fell of his bicycle a week earlier. Had been sent home with broken ribs. Difficulty breathing brought him back. Imaging showed a light region where the lung should be. He had developed a hemopneumothorax. Blood and air needed to be removed, if not successfully in the ER then by a surgeon. Under local anesthetic an incision was made and the whisper or air was followed by gurgling blood. He was sent home with a chest tube.
Case two: teenage girl on bike hit by car. Imaging shows no internal injury but a large wound to her left thigh needed debridement and dressing.
Case three: 20 month old boy bitten around the right eye by pit bull. No one saw the attack. The mother carried the screaming child in. Once calmed by medication, images were taken to look for fractures to the skull and facial bones. The wounds were deep punctures, probably needing eventual cosmetic repair.
Case four: adult male with continuous abdominal pain since previous evening’s meal. All symptoms point to blocked gallbladder…he was the only one scheduled for surgery.
Every case gave me a little more knowledge about some system in the body which I’ll now be able to weave into my anatomy lectures. Classes start next Monday so my summer of shadowing is over. If you ever get a similar opportunity, I encourage you to take it…but not if it involves renting an un-airconditioned room in Sacramento for the summer! Teri
Of all of the medical specialties I knew I’d be seeing, I’ve had the most history with cancer. The first operation I ever learned of was my mother’s mastectomy. She much later was treated for bone cancer. My father and I have had skin cancers removed. So the idea of seeing a patient under the knife was both interesting and hard to dissociate from.
The first major cancer operation I observed was one of the longest. A soft tissue cancer near the chin had invaded the mandible. A team of surgeons from both Oncology and ENT worked in shifts. First they cancer was removed, then the jaw was rebuilt and the neck closed. The most frightening part was that while the surface tissue looked different, to my untrained eyes, I could not fathom how they knew when to stop cutting. Leaving stray cancer cells behind after a surgery of this length would be horrifying. They of course can follow up with chemotherapy or radiation, but the tissues heal more slowly in those cases.
A much more common and shorter surgery is the one my mother had so long ago. A total mastectomy. Not as a pre-emptive strike before cancer, but to remove one that has been found. Working with plastic surgeons the breast can be reconstructed, but not until after the initial wound heals and if necessary extra skin is stretched by an implant. During the mastectomies I witnessed, it was hard not to think of my mom or my own potential risk. I’m glad to know that there are both medical doctors and specialized surgeons training to fight this insidious disease.
Just blood vessels? It struck me as too narrow a field to specialize in. Not as glorious as Cardiothoracic. But now that I have seen them in action, the vascular surgeons are some of my most admired. They deal with some of the sickest patients, for the longest times, and unfortunately for many there is no cure…only help. Here are the three stages of help I’ve seen these surgeons provide.
First, the rarer problem I watched repaired. With no symptoms, only caught by luck on images for something else (yet can run in families so people may have forewarning). An aortic aneurysm that ruptures is lethal, usually even in a hospital setting. So, if one is found they are watched for changes in size. The surgery is risky enough not to go in prematurely. Endovascular surgery allows only puncture wounds in the groin to deploy elaborate stents, but the open surgery is still the standard.
Similar stents can be used in the all too common arterial blockages. Whether anatomical anomaly or the build up of plaque in walls, ballooning the vessel is least invasive, and stenting it a secondary option. We all have at least fatty streaks in our vessels, said one of the surgeons, but hopefully they are not causing ischemia in out tissues. The original surgery (I’ve not observed) to remove the atherosclerotic region especially of carotid arteries is an arterectomy. The area is bypassed, opened, the lining stripped away, and the vessel patched back up. Because it has not foreign material added, the vessel heals itself relatively well but the surgery is much harder on the patient than femoral access for newer methods.
Finally, the sad result of the tissue ischemia. Due to the vessel injuries by diabetes, many will develop neuropathy. The most distal tissues have the longest paths so blood resistance is highest to the feet. When blockages in the lower limbs occur, muscle and skin of toes often die leading to gangrene. The saddest day of surgery I observed was when a whole shift was scheduled for amputations. However, the doctor gave me this bit of encouragement. The sooner he removes a small dead area (single toe at best), the faster the patient is able to get back to their lives.
After multiple shifts with plastic surgeons in the OR they take over after mastectomies or other cancers are removed. They are called to the Emergency room to evaluate superficial , I appreciate not only their physical skill, but the variety of their patients trauma. In clinic, they see those hoping for cosmetic fixes (closing a diastasis between the rectus muscles) and those needing long-term wound care from paralysis. They also work on the damage caused by gunshots (sometimes while the patient is under police guard).
In clinic the residents and medical students do a first pass with each patient, then the attending joins them to finish up. Though a slow process, the teaching that occurs is obvious. One particular case highlighted the need for remembering or reviewing anatomy. The patient, a woman in her early thirties, went to the emergency department on the weekend. She claims to have grabbed the wrong end of a “butter-knife” in order to cut some cake. The cuts on her dominant right hand were located at the metacarophalangeal joints of fingers four and five. After her wounds were cleaned she was asked to move each digit. The pinkie finger would not comply. The residents opened the skin wider to confirm the flexor tendons were intact. While they saw and pulled on one, getting the appropriate response, at this site the superficialis divides and hides. Though they stitched her up and expected all would be well in a week, at clinic the attending took one look at the straight finger and suggested surgery to repair a cut tendon. The residents did no harm, and learned to be a bit more thorough even when called in on such a small injury.
A cardiothoracic surgery to remove masses from the lung amazed me by not only the coordination of the surgeons, but their ability to use imaging and touch. The patient was ventilated as needed for the doctors to reduce the size of the lung tissue to see around inside the chest. Seeing the wounds closed with preloaded rows of staples was an “aha” moment for me.
Wednesday morning: oncology. The patient had previously had their cancerous gallbladder removed by laproscopy, but the margins came back still positive for cancer. Today the surgeons had to open the patient to take out part of the liver. A row of staples won’t work in this case. Cautery, fibrin laced mesh and a tissue gel all helped seal the remaining organ.
Last shift of the week, Friday afternoon to evening. The neurosurgeons had an aneurism to clip. By the time I arrived the right temporal and meninges had already been reflected. The angiogram was displayed on video screens in the operating room. Doppler was used to “hear” if the clipped vessel was completely closed. Before they closed the skull I noted to myself that the brain does not appear as impressive as its many functions truly are, and I don’t think I could be a neurosurgeon. Not due to the physical talents necessary, but for the mental risks involved.
Things I learned in my first week as an intern. Don’t use the elevators or stairs closest to the operating rooms! It was no big deal when the elevator wouldn’t go, it let me back out. The stairs though…require a special card to get out of. Meaning once you get to correct floor you better hope someone else shows up. And when you are supposed to be “early to be on time” waiting around just won’t work.
Plastic surgery isn’t a service I looked forward to observing. It has always struck me as a combination of elective and gruesome. If I got to see reconstructive surgery of an injured child with cleft palate or some other noble procedure that would be great, but no such luck. I got to watch the end of a “bilateral blepharectomy” (eyelid tucks) and facelift. It was amazing the amount of spare skin snipped off after the surgeon finished “loosening up” all that tissue. I wondered if the patient would deem her appearance that big of an improvement…I overheard she’s a college professor.
Urology service had a lecture and their “M&M’s” (morbidity & mortality conference) which wasn’t as exciting as TV. Learned more about catheters than I hope I ever need to know, but still wonder why the bladder’s smooth muscle gets a title (the “detrusor” muscle instead of just calling it the muscularis layer).
Spent whole neurology shift in the OR watching bones being pinned together from osteomyelitis. Lots of titanium went in to hold everything from T-10 to the pelvis together. The surgery was a success, but the patient is elderly, and in renal failure…making me wonder if it was worthwhile.
The most important thing I had to do before observing surgical shifts at the UC Davis Medical center was to get good shoes. The recommendation by former interns: Dansko clogs. The dress code for arriving is business casual, usually followed by a quick change into scrubs.
My first morning I shadowed a resident from the burn service.
Most of his patients were children seen across the street at Shriner’s hospital. In clinic he checked on three boys: one with a dog bite, the next had Steven-Johnson syndrome (see pic) where skin is lost due to a drug interaction, a finally a burn. The worst burn was in an adult from electricity. The treatments are similar since all affected the integument.
Morning rounds with the vascular team were impressive. Starting at 5:15am they raced like a pit crew from patient to patient, not only checking for changes overnight but replacing wound dressings. A large number of their patients are diabetics, feet having the worst circulation. In the afternoon they began an angiogram/stent of a carotid artery. The patient was distressed but didn’t seem to understand her movements lengthened the process greatly. I stayed late and heard the attending checking to see if she had suffered any brain damage…fortunately not.