Reflections on surgery

My surgery rotation is at the ½ way mark, and I’ve now completed my 4 weeks in general surgery and am heading into 2 weeks of urology and 2 weeks of ear,nose & throat. I seem to be concentrating on the orifices. As I told my hairdresser the other day when he asked me if it's just like the tv show "Grey's Anatomy", I said yes, only with less sex. :) It’s been a busy 4 weeks and here are some of the cool things I saw during that time (* squeamish alert here – stop reading now and continue at the next paragraph):

• Holding someone’s slippery intestines in my gloved hands and watching the blood vessels pump blood to them. Very cool. But also very slippery!
• Gallstones. We removed one woman’s gallbladder and she had these massive, rock-hard black-olive like stones in her gallbladder. Here’s what they look like.
• Ostomies. My general surgeon focuses on colo-rectal surgery so he sees a lot of bums, removes a lot of colon cancer and sometimes has to reconnect people’s intestines to their abdominal wall vs the usual bottom connection. It was cool to see how these are done and learn a bit about how they work. I always found them a bit scary before since they were such an ‘unknown’ for me.
• Abscesses – maybe “cool” is the wrong word to describe them, more like dreadfully smelling and gross but astounding in the amount of pus that can come out. One lady had an abscess on her lower back called a pilonidal cyst and I think we drained 2 cups of fluid out of it. Blah! That night I was realizing the value of the little shoe covers they wear sometimes in the OR.
• Lots of cool staplers that cut & reconnect at the same time, electrocautery tools that cut & stop blood flow at the same time and laproscopic cameras & tools that let you do many different abdominal surgeries from just small holes poked in the abdominal wall.
• Feeling & seeing disease. While the patients weren’t fortunate for having these diseases, it was good for me to feel up someone’s bum and feel a rectal cancer from a “digital rectal exam” , to feel a cancerous breast lump, to see what cancer looks like when it’s localized to one spot, to see a polyp in someone’s colon, and to see cancer scattered throughout someone’s belly. It feels hard & definitely out of place.

Other reflections during my time in surgery:

• I had wavered on whether I thought communication skills were as important as technical skills in surgery. Previously I thought so, then at the beginning of surgery I started realizing how important it is to have someone who is good at the actual job of surgery. But the pendulum has swung again after seeing that many times it’s the surgeon who is the first person to give you news of your disease – answering the questions “What is it? How much is there? Where do we go from here?” So once again communication skills come back to the forefront and sometimes, they’re sadly lacking or vague. I’ve seen patients who likely have questions but feel too intimidated to ask them or to clarify what the surgeon means by something, so they wait until I come back again on my own to ask me. I’ll file this away for when I’m a family doc so that I can hopefully be on the ball when pathology results come back from surgeries and be the one to break the news myself in the way I think it should be done. Full of compassion and as much detail as they want to know (more or less, as the case may be).
• I also had the sad experience of having my first patient death during this rotation. We had operated on a man with extensive cancer throughout his belly and a history of Hep C. He did quite well for days after surgery, until day 6 when his health turned and he looked terrible when we went to see him. We reopened him up later that day to find that his reconnection had burst and his belly was full of infection. He barely made it through the surgery – I’ve never seen an anesthetist so busy during a surgery trying to keep his blood pressure up & get him through it. From there he went directly into ICU. The next morning he was barely alive and it was obvious that he didn’t have much time left. Sadly he had no family and no one coming to visit him in hospital and the one contact number we had for a friend was the “wrong number”. As I went into his ICU room, the nurse pulled me outside to say that they weren’t going to try any heroic measures and that she didn’t think he had much time left and that she didn’t know how much he could hear anymore. I went back into his room because I wanted to say something to him that was wise, meaningful and caring. I wanted to say just the right thing in this moment and maybe I thought that when I had this first experience I would know what that was. I didn’t know. I wanted to say I’m sorry we weren’t able to help you, sorry that he got sick so quickly that by the time we went to operate again it was too late, sorry that he wasn’t going to make it and that I’d enjoyed knowing him for the short time that I did. But I didn’t want to seem like I knew he was going to die when maybe he’d pull through. I was thankful for one of the pearls I got from my palliative care course in which they said that hearing is the last sense to leave us, because without that in mind I may have said nothing. With all of that in mind, all I did was put by warm hand on his arm and told him that he was in the best place he could possibly be and that the nurses taking care of him were the best we have and that I’d enjoyed getting to know him. I was talking about this later with a wise friend of mine, lamenting all of the things I should have said but didn’t, but she reassured me that I’d let him know that he was cared for and that’s all I had to offer him at that point. He died a couple of hours later. My surgeon, though he didn’t say too much, was deeply disappointed and upset by this death – taking it as a personal failure. The only thing he said to me was “He should have had a better surgeon.” I reminded him that he was such a sick man with a terminal prognosis, other illnesses and likely wouldn’t have made it much longer regardless. It was true but not that comforting at the same time. But I guess in reality, it was just another day in medicine.

I became a sidekick for my preceptor (aka “my surgeon”) over the month – stuck to him like glue. During that time you do get to know someone pretty well, and once again I saw the power of teamwork – his strength in the technical aspect of surgery and me helping out with patient communication. I think we made a pretty good team & had lots of laughs along the way during surgeries and with patients (including the man yesterday who was more than willing to have me “put on a rubber glove” to examine his bottom in the office vs having my surgeon do it). So the other thing I learned during this rotation is the importance of keeping your sense of humour intact. It sure helps to balance out the tougher days when you can have some good chuckles when the opportunity arises. When I left his office yesterday, I happily got a big hug, a great evaluation and the promise of a good reference letter for my residency application. Not bad for the dreaded surgery rotation, I’d say. :) Once again, I lucked out.