Laparoscopically visualizing anatomic relationships

I recently observed a laparoscopic sigmoidectomy, the removal of the sigmoid colon. The patient's uterus figured prominently in the center of the screen. As the surgeons followed the left descending colon into the sigmoid colon and rectum, I noted that the large bowel tracked posterior to the uterus.


Flashback to a little less than a year ago when as a second-year medical student, lacking any meaningful clinical experience, I was taught how to perform a pelvic exam with a standardized patient. I remember being surprised at the time that a complete pelvic exam includes inserting a finger in the patient's rectum, the purpose of which is to check for cysts or fibroids on the posterior aspect of the uterus.

Afterward, I looked in Netter's to better understand the anatomical relationship between the uterus and rectum. I got it then, but it wasn't until this past week when I saw the actual anatomy directly from inside the abdominal cavity that I really got it.

Anesthesiology

The Surgical Care clerkship includes a one-week exposure to anesthesiology. Admittedly, I entered this week with considerable bias against anesthesiology. It's boring... All anesthesiologists do is put patients to sleep before surgery and wake them up after it's over... There's not much patient interaction... It turns out, though, that my prejudices against anesthesiology were wrong.


The primary job of anesthesiologists, medically speaking, is to keep the patient alive and stable, numb, asleep, and motionless, so the surgeons can do their job.

Anesthesiology is mostly applied physiology and pharmacology. It's the application that interests me. Anesthesiologists use drugs and the ventilator machine to micromanage a patient's vital signs for the duration of the surgery and immediately afterward. Physiologic changes take place right before your eyes. Push propofol and watch the patient fall asleep, completely unarousable. Push rocuronium and watch them stop breathing. Push phenylephrine and watch their blood pressure rise and their heart rate drop. Instant gratification.

Minor procedures are another component of the anesthesiologist's job description: placement of arterial lines and central lines, epidurals, spinals, and of course endotracheal intubations.

I couldn't get enough of the procedures. Over the past week, I placed my first arterial line (after one failed attempt), and my entrotracheal intubation record was 6 successful placements for 13 attempts. Pretty good for a third-year medical student, I was told by my anesthesiology mentor, but he was probably just trying to encourage me. An actual anesthesiologist needs to have a perfect record.

I was also struck by how happy and well adjusted everyone seemed to me. One anesthesiologist just got back from a trip to the Galopagos Islands, and another partners with a team of surgeons on regular missions to Africa. At lunch one day, we determined that all six anesthesiologists at the table were runners. My anesthesiology mentor actually runs 5 miles to and from the hospital a few times per week! I felt like I fit in.


Now, I'm left feeling more confused about my future than ever. I had to write out a list of pros and cons for anesthesiology:

Pros:

• Optimal lifestyle
• Lots of procedures
• Taking away pain makes people happy
• Instant gratification
• No rounds
• Work in the OR, get to wear scrubs to work
• Happy, interesting, and active colleagues
• Good compensation

Cons:

• Does not fit the archetype of a physician that I have carried in my mind since childhood
• No longitudinal patient contact and minimal face-time with patients
• Not the star of the show

Surgery is halfway over

That went by quickly. Mid-point gut check: I like surgery, I like doing procedures, I'm willing and capable of working the long hours required of a career in surgery, and I think I would be a good surgeon. But I'm still very skeptical about the lifestyle issue.

Feeling useful as a third-year medical student

During my last call night, I worked with an upper-level resident who treated me more like a sub-I than a third-year medical student. "Go get a history and physical on this new patient in the ED. I'll see you in 20 minutes." I can't emphasize enough how much I appreciate this management style. He gave me a clear task, he clearly communicated his expectations of my performance, and those expectations were appropriately high. I'll go out on a limb, here, but I think that I was actually useful that night. This is something to hold onto given that I have felt decidedly not useful during much of third-year so far.

Daylight savings

Another perk of being in the middle of my surgery rotation now:

Fall daylight savings. Tomorrow morning when I wake up at 4:15, it'll feel like 5:15. Too bad that effect wears off after a few days.

Desensitization to grossness

I finally saw the movie Contagion, which is about the the human response to a viral epidemic in its first days and weeks. Fascinating movie. Fairly realistic, too, according to one expert. Without spoiling the movie, there was one graphic autopsy scene during which the whole audience groaned in disgust. I chuckled to myself at the dramatization and realized how far I've come through my medical education in the process of desensitizing myself to sights and experiences that would make most people queasy.

My experience in the OR so far

Once I got past the physical demands of standing in place for hours on end, I quickly realized that spending time in the OR observing surgeries is my favorite part of the surgery clerkship. Depending on the day's OR schedule and whether there are any didactic sessions in the afternoon, I might see anywhere between 1 and 5 surgeries in a given day. So far, I've tried to give myself a wide variety of cases, which represent the vast majority of bread-and-butter general surgery. These include:

• Laparoscopic appendectomy
• Laparoscopic cholecystectomy
• Colectomy with end ileostomy
• Ileostomy takedown
• Direct inguinal hernia repair
• Femoral hernia repair
• Epigastric hernia repair
• Thyroidectomy
• Breast lumpectomy

I've also had the opportunity to stand in on some surgical sub-specialty cases: laser transurethral resection of the prostate (TURP) with a urologist, vitrectomy with an ophthalmologist, biopsy of a posterior tongue mass with an otolaryngologist. I'm really grateful to have exposure to the surgical sub-specialties because I elected to do general surgery for all 8 weeks of this clerkship. I know that I don't want to be a urologist or otolaryngologist. I was fascinated by the eye surgery, though, and plan to observe more of them.


Here's a rough breakdown of what my OR time looks like:

50% - Standing quietly behind the attending or resident, trying to stay out of the way, and waiting to be pimped or rewarded for my good behavior with a gift from Above.
40% - Human retractor. Special features: Retracts 360 degrees along all three axes; Variable tension; Responds to verbal and tactile commands; Central processor allows for experience-based learning and adaptability.
5% - Sewing up laparoscopic port incisions or tying knots.
The remaining 5% - Split between driving the laparoscopic camera, electrocauterizing vessels, and other odd jobs.

Climbing the ladder

One of my surgery attendings likened a career in surgery to going through junior high school all over again, every few years. You graduate medical school thinking that, finally, you're climbing your way up the ladder, only to realize that you're just an intern. Interns are dirt: they take care of all the jobs that residents and attendings don't want to deal with and that medical students aren't allowed to do.

You progress through residency and think you're hot stuff by the time you're a chief resident, then you do a fellowship and realize that fellows are dirt, too, low suregon on the totem pole in that given sub-specialty.

Then you finish fellowship and get a job in the real world thinking that finally you've made it, except you realize that you're the most junior member of the practice. Everyone else is looking at you like, "So you think you're a surgeon now, huh? We'll see about that."

It's a recurring process of having to prove yourself to those with more surgical experience. Every few years, you'll be the new kid on the block who everyone picks on. Until you're old and gray, there will always be someone more senior who will serve it to you.

What I found most amusing about his analogy is that medical students aren't even on the proverbial ladder. This correlates strongly with what I've observed so far, that surgeons in general tend to avoid recognizing the presence of medical students except in the function of teaching.

Exhausted

I'm post-call today, meaning I just came off a 28-hour work day. Slept less than an hour last night. My resident called last night a 7 out of 10 in terms of how busy we were. It's the first call night I've experienced that is actually representative of what call is really like for interns and residents.

This was the fourth call night I've taken in 12 days. We have to take call a total of 6 nights spread over 8 weeks. I front-loaded on purpose for two reasons: 1) so I will have more time and energy available toward the end of the block to study for the departmental exam, and 2) to experience the exhaustion that surgery interns and residents have to go through taking overnight call every 3-4 days.

So, how did I handle it? I was surprised by how easily I stayed awake and alert when there was action, like when I had to get a history and physical exam from a patient in the Emergency Department or lay eyes on an unstable ICU patient.

I also noted with some sadness how I had much less patience for the circumferential responses my patients would give to open-ended questions like "Tell me why you're here tonight." What I really meant, I realized, was "Tell me why you're keeping me from sleep." Even as much as I wanted a busy call night, it's amazing how sleep deprivation makes everything except sleep seem much less important.

I hope that my impatience wasn't apparent to my patients in the way I interacted with them. This is something for me to keep an eye on in the future when I'm similarly exhausted.

Ironic, I thought when 4am rolled around and I had been working all night, that this is the time when I would have been waking up for the next day's work. It used to be much later. I learned that a half-hour "nap" before pre-rounds can make a huge difference in getting me through the rest of the morning.