Memorial Day at the Veterans Hospital

Typical Wound Rounds

It was one of those typical wound rounds days at our VA Hospital. We made our (the complete vascular surgical team) over to the long-term care wing of the hospital to do our weekly check of patients who didn’t have formal vascular clinic appointments or who were bedridden with chronic wounds. The mid-level practitioners would put names of patients on a list at the nurses station for us to check. The patients who were ambulatory or wheel-chair bound would return to their rooms so that we could check them as we made our way down a T-shaped hallway with two long wings. The entire process generally took from 2-4 hours depending on how many patients to see and how extensive the wounds were and what care was needed.

The hallways

Most of the rooms down these hallways were semi-private (2 vets to a room) with a ward (4 vets to a room) at the proximal ends. At the end of the hallway were the private rooms for those vets who were in isolation for infections or for those who were too loud or ventilated and would not be amenable to sharing a room with another vet. The rooms at the far end of the hallway, though private, had views from the window that rivaled any 4-star hotel. They overlooked the front grounds of the hospital and the baseball diamond. Flying in the breeze was the state flag, the POW-MIA flag and the flag of the United States. The entire VA complex sat upon a hill that overlooked the surrounding town and mountains in the distance. No matter what time of year, the views were spectacular and I always paused to admire nature’s show for these men who had given so much.

Chronic Wounds

We made our way from room to room. Many of these patients were post toe amputations and needed wound checks. Others were diabetic with foot ulcers from poorly fitting shoes or injuries that they could not feel and thus the wounds had become infected. Many of the vets were long-time smokers and diabetics with peripheral vascular disease from smoking and neurovascular disease from their diabetes. Some were despirately trying to “keep their feet” while others had both lower extremities amputated starting with the toes, then the feet and finally the leg above the knee. With each room change, there came a new challenge or a new evaluation. We removed dressings, evaluated vascular supply and made recommendations for each patient. With each week, I grew to know these patients and to learn to predict whether the wounds would heal, or an intervention was needed, or progression to limb amputation. Sometimes it wasn’t wonderful to tell a patient that he would lose his foot but a good amputation with a well-healed stump could mean a return to ambulation and increased freedom. It was the progression of things each week.

Moving toward the end of the hall

This week, we decided to divide the duties with the interns doing post op checks and the more senior residents examining those patients who needed evaluation for possible surgical interventions. I elected to see the last two patients who were bedridden and in isolation for MRSA (meth resistant stap aureus). I knew that these guys had extensive wounds that would take some time inspect, debride and re-dress. I loaded my pockets with enough bandages for the dressing change and left my coat on the cart outside of the door as I donned the yellow isolation gown, a mask , gloves and shoe covers. I greeted my first patient and set to work removing the old dressings. We had ordered that dressings be changed every six hours on this patient but it was clear that his dressings were being changed daily instead of three times daily. How was this wound going to heal? It’s the wet to dry dressings that debride the wound and help to clear the necrotic tissue that would promote healing. I chatted with “George” as I completed the inspection and dressing change. I left my initials, the date and time on the outside of the dressing. If this was still here in the AM (I had planned to stop in early and check), I would be writing an incident report. If George was to keep his leg, this dressing needed to be changed. For George, a very pleasant gentleman who was post stroke, this was limb salvage.

The last room

I moved into Fred’s room after I cleaned up and washed my hands from George’s wounds. It was now well past dinner time and the sun was low in the sky. Fred’s bed was facing the beautiful setting sun. Fred had congestive heart failure, diabetes and emphysema. He was a small thing gentleman with bright blue eyes that still held a twinkle when you greeted him with “Semper Fi”. Fred had been a marine and by his looks, a real scrappy guy. I always chatted about baseball with him and he loved the company. Sometimes he sang “Take Me Out to the Ballgame” off key as I worked on his infected decubitus ulcers. Twice we had taken Fred to the OR for surgical debridement where we cleared away foul-smelling dead tissue down to the bone. Fred had little tissue left on any of his pressure points and had been failing rapidly.

Today, Fred appeared to be dozing quietly in the setting sun. I touched his hand which was wrinkled and warm. I noticed that Fred wasn’t breathing and had likely died a few minutes earlier. He looked peaceful and happy as the sun’s last rays of the day were settling on him. On the ball field, one of the local town teams was finishing up a game. Most likely, the last thing that Fred saw was his beloved baseball and a beautiful May sunset. To the man who had given so much so that I could come and dress his wounds, God had given one last baseball game in sunset.

There are thousands of veterans in hospitals around the country presently. They love company and they don’t care if you are not related to them. They are very appreciative of everything that we do for them. Many times, the interns and medical students would complain about wound checks but for me, they are the highlight of my week. I might make a difference that will allow a vet to keep his feet or I might be reminded of how special these guys are and why I love what I do and have the opportunity to do it because of them

Why I chose Surgery (Part 1 and Part 2)

Part I (an earlier post)

I can vividly remember starting my third year of medical school. My school chose our third-year schedules for us and I remember some of the angst of my fellow classmates when our schedules were posted during the summer between our second and third years. I was in the midst of a wonderful Pathology fellowship that I had received for scoring very high in my Pathology course. I was assigned to various Medical Examiners offices and to the Pathology Departments of a couple of very large teaching hospitals. I had been spending the summer doing everything from crime scene investigation to transfusion medicine to bone marrow transplant. It had been a great summer. I was very strongly considering Pathology and Transfusion Medicine as my specialty.

I stopped by my Dean of Academic Affairs office and was told to wait for my USMLE Step I scores. The school had received them before I had received them. I took a deep breath because I really hadn’t prepared myself for facing the prospect that I might have failed that test. I sat in a chair outside the Dean’s inner office and ran a couple of scenarios as to what I would do if I had failed. I would quickly sign up for a retest and I would only miss one rotation at the start of third year. Since I was doing Pathology, I could study in between cases and get my preceptors to help me with covering the material.

The Dean came out and handed me a sheet of paper. I had to just sit there in disbelief. Not only had I passed, I had done extremely well. I was on my way. It was hard to hold back the tears of joy because I had studied about two and a half weeks for Step I. My fellowship had the requirement that I take Step I by the second week in May and my last exam from second year was on April 28th. I would be starting third year and I would be starting third year on Pediatrics with one of my best friends as my rotation partner. Life was good… I found out later that two people from my class did not pass USMLE Step I. It was very sad because one girl ran down the hall screaming and sobbing when she received her score. That put loads of people on edge.

I started third year on Pediatrics. It was a good rotation and I received Honors. I really enjoyed taking care of patients and I was very popular with the residents because I could place IVs and draw blood. I had also spent loads of time with an excellent pediatric pathologist so I knew my congenital defects inside and out. I could interpret cath reports and I was quite comfortable in the Pediatric Intensive Care Unit. I had been a Pediatric-Perinatal Respiratory Therapist before starting medical school so the interns found me quite useful.

My second rotation was Psychiatry. This was one of my best required clerkships. I knew that I wasn’t going into Psychiatry (you know these things early) so I was free to enjoy the rotation and pick up anything that I could. My preceptor was an excellent Consultation-Liaison Psychiatrist who exposed us to everything from the wards for the criminally insane to hard-core substance abusers to schizophrenics and other stuff. I earned another Honors grade and got some excellent experience. I learned above all that I was not crazy, my friends are not crazy because I spent loads of “quality time” around people who were genuine crazy.

My third rotation was Family Medicine. I had a great preceptor who even delivered babies. This rotatations was entirely office based but I learned to do prenatal exams and care for entire families. I also learned how and when to refer which is great stuff to know. My preceptor was extremely brainy and “pimped” me on just about everything. Turns out this was a good test for USMLE Step II because we either discussed or I had to report on most everything in Family Medicine that was on the shelf exam or on USMLE Step II. I received Honors for this rotation but decided that I really did not enjoy being out of the hospital too often. I also did not enjoy the slow pace of the office.

Holiday break came and I was happy to be done with shelf exams and rotations for five weeks. I knew that Surgery was coming up and my friends had warned me to be ready for two months of pure hell. The rotation is designed so that you spend your first month on General Surgery on one of two services: Trauma or General Surgery. I drew Trauma out of the hat and I received the condolences of my classmates. I figured, “you can do anything that you want with me but you can’t stop that clock.” No matter how bad, in four weeks, it would be over.

I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn’t wait to be on call every third day. I had the time of my life and I loved everything about surgery.

My next month was spent on ENT and then on Cardio-thoracic and Vascular Surgery. I scrubbed every case that was assigned to me and many cases that were assigned to some of my colleagues. I became hooked on Vascular Surgery during that rotation. I loved the detective atmosphere on Vascular and loved taking care of the patients. My chief resident on Vascular taught me some great pearls about making sure that even with an amputation, fashioning a well-constructed stump can make the difference between ambulating and not ambulating for the patient. It was great stuff.

After Surgery, I rotated through OB-Gyn. I hated everything about this specialty. This rotation became my only High Pass during third year. I just couldn’t get into delivering babies and I wasn’t thrilled with tubal ligations. I wasn’t thrilled with spending too much time in the clinics and offices. The one bright spot was the Gyn surgeries which I excelled at. I learned the surgical anatomy like a sponge but I knew that this was not going to be the specialty for me.

I finished up on Medicine and Neurology. This would be my final sixteen weeks of third year. I was fortunate to have medicine last because this made study for USMLE Step II a snap. I totally enjoyed Medicine and Neurology but my heart was back in surgery. All of my Pathology experience really paid off because I aced these rotations and moved onto fourth year.

My faculty adviser was chairman of surgery and helped pave the way for my entry into this specialty. I was also co-president of the Surgical Society during my fourth year which also helped. My USMLE scores were good so this helped too. I had some awesome interviews and I landed at a great residency program. My experiences began there and they keep on.

As I continue to write, I will be posting more of my experiences.

Part 2 Why I chose Surgery.

As I moved through medical school, I knew that any specialty that I would enter had to have the following aspects:

• Ability to have long-term relationships with patients
• Ability to see every type of patient under a variety of circumstances
• Practice in office, clinic, hospital, intensive care, operating room and emergency department.
• Ability to handle a wide variety of clinical conditions
• Ability to deal with both acute and chronic conditions
• Ability to perform many procedures

The only specialty that met all of those requirements for me was Surgery. I also loved the aspect that I had to utilize my knowledge of both medicine and physiology to the surgical patient both preoperative and postoperatively. This was very appealing for me. I also utilize pathology and biochemistry to a great degree especially in my teaching of surgery and surgery practice. Again, this made surgery a very attractive specialty.

I definitely started out in residency with a strong interest in vascular surgery. Not only were the vascular surgical patients among the sickest in the hospital on any given day, I also loved seeing the immediate aspects of my work. Once you increase blood flow to an extremity that had previously been lacking blood flow, you see the immediate effects both good and bad. I also liked becoming very familiar with wound care and the healing of chronic wounds.

I had heard about the “surgical personality” and that some surgeons were very difficult to deal with but that never became a factor in my choice of specialty. I don’t care if the devil himself is teaching me if the teaching is good. Fortunately for me, that was rarely the case and my knowledge base expanded exponentially with every year of training. Good teaching is good teaching and good faculty allow you to grow and learn from both them and your mistakes in a constructive manner. I also found that I could profit from the mistakes of others at time too.

The other factor that did not deter me from surgery was the horror stories that I had heard about the residency experience. Yes, sometimes I had to work long hours but those long hours yielded some of the best teaching of my life. Yes, I did miss parties and social events but that happens with any aspect of medicine and comes with the territory. Physicians often work long hours taking care of patients who are sick. If you don’t like to take care of sick patients, medicine/surgery is not the career for you.

Finally, I have a very good life. I do something that is very interesting and I give my patients 100% at all times. I have encountered some physicians who were psychotic, neurotic, dishonest, unprofessional, racist, sexist, anti-Semitic and just down right stupid. The interesting thing is that I am none of those things and my life is good.  Good will goes out from me to my patients and it come back to me in droves. Yes, I work very hard and under extreme conditions at times but I have been blessed with an even temper and a love of my fellow humans.

If you choose a specialty, choose for what you know that you will enjoy doing in most aspects for the rest of your life. If not, you have many years of misery ahead of you. Conditions of practice will change and your income is largely based, not in how hard you work, but on what third-party payers are willing to pay for your services. If you can’t deal with this aspect of your chosen profession, get out as soon as you can.

If you choose a specialty because the rest of your classmates were in awe of you, you are likely going to be very unhappy in that specialty. Specialty choice is personal and your classmates will not be entering residency or practice with you. You, and not your classmates, will be the person at 0400h who is admitting that patient with the chronic condition, thousands of medications and multiple needs. You have to love that aspect of medicine/surgery as much as you love the other aspects of medicine/surgery.

Finally, you have to be a ethical and honest person. Showing up at the church door every Sunday does not make you a moral person if you know that deep inside yourself, you couldn’t be honest with yourself, your patients or your colleagues. You may not ”like” everyone that you work with or work on but you have to have respect for them and give them your best. In short, you can’t be having a “bad day” unless you are on vacation. If you are prone to allowing external influences to influence you internally, you are going to have a difficult time medicine/surgery.

Especially with surgery, you will find yourself multi-tasking, juggling six or seven balls at once, shifting up and shifting back on a daily basis. That’s the nature of the work and the challenge of the work. If you can’t do this, surgery is going to be tough for you on a regular basis.  In short, I have never had a day that was strictly “routine” unless I was just teaching for the entire day.

Finally, take some time and get to know yourself and your career needs because after all, this is YOUR career. Your parents, your significant other, your classmates or anyone outside of yourself, can’t make this decision for you. You have to know your competitiveness for certain specialties (forget derm if you struggled with every aspect of medical school including boards) and you have to have a good idea of how competitive you are for programs within that specialty.

Also, remember that while residency is when you will hone your skills, it is a short period out of the length of time that you will actually practice those skills. Again, I heard that surgical internship was the worst time on earth but I actually enjoyed my experiences during internship. I heard that surgical residency was the worse time on earth but it wasn’t. No residency program is going to be perfect but unless you encounter dishonest or illegal activity, you can live with residency. The clock is always ticking and time passes (quickly in most cases).

Residency requires hard work and hard study. In my case, during my first two years of residency, I studied far more than at any point in medical school in addition to getting my work done. At times, I was “bone tired” but I made myself read and study (minimally for 30 minutes daily). No, I didn’t get to the gym as often as I would have liked and I didn’t hang out late at night (outside the hospital) but I did live pretty well and my significant other saw as much of me as he could stand anyway.

Surgical Clerkship 101 (Part 2)

This is the second of a three-part series to help you get the most out of your third-year surgical clerkship. Since this is one of the most important required clerkships, I thought I would spend some time on this one. The subject matter of this essay will be scrubbing and assisting in the OR along with handling some of the “pimp” questions that frequently come during the cases.

Your first tour at the scrub sink need not be intimidating as long as you keep a couple of things in mind. First, you need to be dressed properly. By proper dress, I mean clean hospital scrubs with no T-shirt sleeves below the level of the scrub sleeve. You need to have your hair completely covered (no bangs sticking out ladies) by scrub cap or “shower-type” cap.  These caps should be clean and ideally, disposable. You need to have eye protection that covers all around. The goggle-type glasses are the best but you can pick up the disposable “Angel Frames” which are better than nothing at all. Blood spatters in the eyes are no laughing matter and you need to be protected. After your eye protection is in place, you must don a mask that completely covers your mouth and nose. If you have a beard or large bushy mustache, you can wear one of the hooded type devices that serve as both cap and mask. Finally, you need to don shoe covers that completely cover your shoes including the laces. Blood and other fluids often drip down onto your shoes. If you have shoes without laces, so much the better. I have shoes that I do not wear outside the OR that I cover with two pairs of shoe covers. When I am done with the case, I dispose of the outer cover and keep the inner cover for the recovery room.

You need to put on your hat and shoe covers before you enter the operating suite. These are usually at the door or near the door of the locker room and within easy reach. You need to be sure that your scrubs are clean before you leave the locker area (no blood or coffee). At the scrub sink, you need to don your mask and eye shields. Make sure that your mask is under the rim of your eye shield and tight. If moisture gets through, your eye shields will fog during the case and you won’t be able to see. Place a small piece of tape if you can’t crimp the mask for a custom fit. (Some people will tie a face shield-type mask upside down on their forehead to prevent fogging. This works well and you don’t need the eye shields if you do this. Another advantage of the upside-down face shield is that the rolled up mask part acts like a wick if you sweat or are doing a peds case in a very warm room. Before you begin to scrub, go into the operating suite, introduce yourself to both the circulator and scrubbed personnel and write your name on the board and your level (MS-III). Also, if you are wearing a pager, place this on the desk with a pen/small note pad clipped to it. You can’t answer your pages when you are scrubbed in a case. Obtain your gloves and gown and place them on the table where the circulator can open them and hand off to the scrubbed assistant. Be sure to obtain both pairs because you want to be double gloved. Be sure you have chosen the correct size (have one of the nurses/techs size you if you don’t know). I wear size 7.5 gloves (big hands) I place my 8 undergloves next to my skin and put size 7.5 on top. Gloves that are too tight will be miserable on a long case. Gloves that are too loose do not permit good tactile skills such as suturing.

Once your mask, hat and eye protection are in place, you should be standing in front of the scrub sink. There are two types of soap solutions available (the waterless and water requiring). If you use the waterless scrub, make sure that you have done at least one water-based scrub before you use this material. On vascular cases, I never use the waterless scrub alone and usually do a full scrub between cases. If a graft gets infected, the patient usually dies from that infection. I take no chances and always err on the side of caution. If you are allergic to iodine (and I am allergic to iodine) don’t use the povidine solution for scrubbing. You should have gone through a “scrub class” before you actually scrub but the short version is here.

Take the nail cleaner and scrub brush from its packet. Turn on the water with your foot (may be automatic) and wet your hands and arms starting with the hands and going up to the elbows. Be careful not to touch the faucet. Use the nail cleaner to clean under each nail and dispose of it. Scrub each surface of each finger with plenty of soap and the brush. Divide your arms into four quadrants and clean them using 25 strokes for each finger surface, the nails of each hand, the surface up to the elbow. Once you have scrubbed an area, don’t re scrub. Toss the brush into the trash can and rinse starting with the hands and letting the water drip at the elbows. Keep your hands up at all times. If you accidentally touch the faucet, start over with the scrub.

You will drip water but hold your hands up and open the door of the operating room with your rear end. The scrubbed person will give you a sterile towel. Allow them to drape this towel over your wet hands. Grasp the towel at one end with one hand and dry from hand up to elbow. Take the other end and do the same. Drop the towel across the laundry hamper or where you are told to drop it. You hands should be dry and continuously held up. The scrub person will hand you a gown or drape a gown over your shoulders (stand still and close enough) pulling up the sleeves. The circulator will tie the gown. The scrubbed assistant will place your under glove on your right hand (left first at Mayo) and then you use your index and long finger to stretch the second glove so that you can place it on your second hand. This is repeated for you outer glove.

 You then “spin” and tie the outside ties of your gown. At this point, if you are not doing anything, cross your arms and stand out of the way. The resident and attending surgeon will be draping the patient and will tell you where to stand and what to do. Keep your arms folded and once you are in place, keep your hands “in the case” meaning let them rest on the OR table in complete view of the scrubbed assistant. When the surgeon gives you a retractor, hold it as instructed and try not to move. Keep your mind on the case, step by step (you should review the procedure before entering the OR). The surgeon may ask you to do a couple of ties or throw some sutures. Be sure that you are totally familiar with whatever you are asked to do. If it’s your first time, speak up and someone will talk you through. Try to close the skin at the end of the case. At this point, you and the resident can share this duty and it’s a good time to learn.

If you are driving camera on an laparoscopic case, try to keep the instruments in the center of the visual field. Believe it or not, you have the most important job on the case. Good camera drivers usually get excellent evaluations from the residents and attendings so learn this important skill. In the event of an emergency and you lose gas pressure, remove the camera as quickly as possible. The light on the end of the camera can cause a very serious burn so you need to be sure that you don’t touch any tissue with the light and that you remove the camera efficiently if told to do so. Keep your eyes in the case and listen to instructions. If you make a mistake, correct it but don’t take anything personally. When a case isn’t going well, surgeons can get frustrated. It isn’t personal and don’t let it throw you.

At the end of the case, help the anesthesiologist, resident and technician move the patient to the stretcher and push the stretcher to the recovery room. Again, just do what you are told if you don’t know. Step up and volunteer your assistance if needed. Watch tubes and IV lines on transfer and remember that the anesthesiologist directs the move because he/she is in charge of the airway. Be sure to thank the OR scrub staff when you leave the OR for the recovery room. It’s just common courtesy. Once in the recovery room, be ready to write the ”Brief Op Note”. You can get all of the components from the anesthesiologist and the OR nurse. At the beginning of your rotation memorize the components of the Brief Op Note and be efficient at getting this note written. Again, ask to do this and ask the resident to help you if you can’t find something. Don’t leave this note incomplete. When I am dictating the case, I will use this note in my dictations so listen to the resident’s dictation (I dictate my cases in the RR at the end of each case) if nothing else.

Every patient that you assist on that is coming to your service will be your patient. If you have seen the case, you know what the incision looked like at the close of the case and you know what went on during the case. Keep these things in mind as you follow your patient. Be sure to read the anesthesia notes on your patient and ask questions if you don’t understand something. These notes can be invaluable in terms of fluid management of your patient post-op.  

Answering those “pimp” questions. Most questions asked during a case will be directly related to the pathology of the patient or the anatomy of the region that involves the pathology. Be sure that you have reviewed these things before scrubbing the case. It’s a good idea to review the anatomy of the biliary system, the GI system and the chest before you start your rotation. Be sure to read and review common emergency cases such as appendicitis, acute abdomen  and vascular anatomy.  After that, read about the types of patients that you will be seeing on your service. Finally, cover trauma (unless you are on trauma service). Again, the Lawrence text is great for reading and total mastery of this book can take you a long way toward doing well on your shelf exam.

You also need to be sure that you skills are adequate. Practice with a knot-tying board until you can tie a secure two-handed knot without thinking about it. Be sure to bone up on your fluid and electrolyte information as pimp questions will frequently come for this subject matter. Stick close to your resident and don’t whine. If you are tired, your intern and resident is more tired. There will be times where you are just exhausted. The first thing you should grab is a bottle of water (dehydration makes exhaustion worse). Stay away from loads of caffeine and sugar and learn to “cat-nap”. Be upbeat and remember that no matter how bad the rotation, the clock is ticking and it will be over soon. For most people, this is their only brush with surgery and the most important thing to take away from the rotation is a solid knowledge of when to consult a surgeon.  Next essay, when things go wrong and how to do “damage control”.